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Sienna J, Kahalley LS, Mabbott D, Grosshans D, Santiago AT, Paulino ADC, Merchant TE, Manzar GS, Dama H, Hodgson DC, Chintagumpala M, Okcu MF, Whitehead WE, Laperriere N, Ramaswamy V, Bartels U, Tabori U, Bennett JM, Das A, Craig T, Tsang DS. Proton Therapy Mediates Dose Reductions to Brain Structures Associated With Cognition in Children With Medulloblastoma. Int J Radiat Oncol Biol Phys 2024; 119:200-207. [PMID: 38040059 PMCID: PMC11023754 DOI: 10.1016/j.ijrobp.2023.11.035] [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: 07/17/2023] [Revised: 10/27/2023] [Accepted: 11/19/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE Emerging evidence suggests proton radiation therapy may offer cognitive sparing advantages over photon radiation therapy, yet dosimetry has not been compared previously. The purpose of this study was to examine dosimetric correlates of cognitive outcomes in children with medulloblastoma treated with proton versus photon radiation therapy. METHODS AND MATERIALS In this retrospective, bi-institutional study, dosimetric and cognitive data from 75 patients (39 photon and 36 proton) were analyzed. Doses to brain structures were compared between treatment modalities. Linear mixed-effects models were used to create models of global IQ and cognitive domain scores. RESULTS The mean dose and dose to 40% of the brain (D40) were 2.7 and 4.1 Gy less among proton-treated patients compared with photon-treated patients (P = .03 and .007, respectively). Mean doses to the left and right hippocampi were 11.2 Gy lower among proton-treated patients (P < .001 for both). Mean doses to the left and right temporal lobes were 6.9 and 7.1 Gy lower with proton treatment, respectively (P < .001 for both). Models of cognition found statistically significant associations between higher mean brain dose and reduced verbal comprehension, increased right temporal lobe D40 with reduced perceptual reasoning, and greater left temporal mean dose with reduced working memory. Higher brain D40 was associated with reduced processing speed and global IQ scores. CONCLUSIONS Proton therapy reduces doses to normal brain structures compared with photon treatment. This leads to reduced cognitive decline after radiation therapy across multiple intellectual endpoints. Proton therapy should be offered to children receiving radiation for medulloblastoma.
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Affiliation(s)
- Julianna Sienna
- Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Lisa S Kahalley
- Division of Psychology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Donald Mabbott
- Department of Psychology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anna Theresa Santiago
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Gohar S Manzar
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hitesh Dama
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - David C Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Murali Chintagumpala
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Mehmet Fatih Okcu
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - William E Whitehead
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ute Bartels
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Julie M Bennett
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anirban Das
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tim Craig
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Byrne EM, Pascoe M, Cooper D, Armstrong TS, Gilbert MR. Challenges and limitations of clinical trials in the adolescent and young adult CNS cancer population: A systematic review. Neurooncol Adv 2024; 6:vdad159. [PMID: 38250563 PMCID: PMC10798804 DOI: 10.1093/noajnl/vdad159] [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] [Indexed: 01/23/2024] Open
Abstract
Background The adolescent and young adult (AYA) cancer population, aged 15-39, carries significant morbidity and mortality. Despite growing recognition of unique challenges with this age group, there has been little documentation of unmet needs in their care, trial participation, and quality of life, particularly in those with primary brain tumors. Methods A systematic literature review of 4 databases was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Studies included editorials, reviews, and practice guidelines on the challenges and limitations faced by the AYA population. Papers had to address CNS tumors. Results Sixty-eight studies met the inclusion criteria. The challenges and limitations in clinical trials in the AYA population were synthesized into 11 categories: molecular heterogeneity, tumor biology, diagnostic delay, access to care, physician factors, patient factors, primary brain tumor (PBT) factors, accrual, limited trials, long term follow up, and trial design. The published papers' recommendations were categorized based on the target of the recommendation: providers, coordination of care, organizations, accrual, and trial design. The AYA cancer population was found to suffer from unique challenges and barriers to care and the construction of trials. Conclusions The AYA CNS cancer population suffers from unique challenges and barriers to care and construction of trials that make it critical to acknowledge AYAs as a distinct patient population. In addition, AYAs with primary brain tumors are underrecognized and underreported in current literature. More studies in the AYA primary brain tumor patient population are needed to improve their care and participation in trials.
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Affiliation(s)
- Emma M Byrne
- Neuro-Oncology Branch, National Cancer Institute, National Institute of Health, Bethesda, Maryland, USA
| | - Maeve Pascoe
- Neuro-Oncology Branch, National Cancer Institute, National Institute of Health, Bethesda, Maryland, USA
| | - Diane Cooper
- National Institute of Health Library, National Institute of Health, Bethesda, Maryland, USA
| | - Terri S Armstrong
- Neuro-Oncology Branch, National Cancer Institute, National Institute of Health, Bethesda, Maryland, USA
| | - Mark R Gilbert
- Neuro-Oncology Branch, National Cancer Institute, National Institute of Health, Bethesda, Maryland, USA
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3
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Gabay S, Merchant TE, Boop FA, Roth J, Constantini S. Shifting Strategies in the Treatment of Pediatric Craniopharyngioma. Curr Oncol Rep 2023; 25:1497-1513. [PMID: 38015373 DOI: 10.1007/s11912-023-01471-9] [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] [Accepted: 10/16/2023] [Indexed: 11/29/2023]
Abstract
PURPOSE OF REVIEW Craniopharyngiomas represent one of the most challenging diseases to treat. Despite their benign histology, and after many decades of surgical experience and technological advancements, there is still no clear consensus regarding the most effective management for this tumor. Due to their location and aggressive local characteristics, purely surgical approaches all too often result in unacceptable morbidity. RECENT FINDINGS Partial resection combined with radiation therapy results in similar control rates when compared to aggressive surgery, while also minimalizing the neuro-endocrinological morbidity. In this manuscript, we describe the historical progression of the shifting strategies in the management of pediatric craniopharyngioma. Time has also altered our expectations for outcomes, evolving from purely morbidity and mortality to simple Glasgow Outcomes Scales, now to formal neuro-psychometric and quality of life data.
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Affiliation(s)
- Segev Gabay
- Department of Pediatric Neurosurgery and Pediatric Brain Institute, Dana Dwek Children Hospital, Tel Aviv Medical Center, 6 Weizmann Street, 64239, Tel Aviv, Israel
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Frederick A Boop
- Department of Neurosurgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jonathan Roth
- Department of Pediatric Neurosurgery and Pediatric Brain Institute, Dana Dwek Children Hospital, Tel Aviv Medical Center, 6 Weizmann Street, 64239, Tel Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery and Pediatric Brain Institute, Dana Dwek Children Hospital, Tel Aviv Medical Center, 6 Weizmann Street, 64239, Tel Aviv, Israel.
- Tel Aviv University, Tel Aviv, Israel.
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Gaito S, Aznar MC, Burnet NG, Crellin A, France A, Indelicato D, Kirkby KJ, Pan S, Whitfield G, Smith E. Assessing Equity of Access to Proton Beam Therapy: A Literature Review. Clin Oncol (R Coll Radiol) 2023; 35:e528-e536. [PMID: 37296036 DOI: 10.1016/j.clon.2023.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023]
Abstract
Proton beam therapy (PBT) is one of the most advanced radiotherapy technologies, with growing evidence to support its use in specific clinical scenarios and exponential growth of demand and capacity worldwide over the past few decades. However, geographical inequalities persist in the distribution of PBT centres, which translate into variations in access and use of this technology. The aim of this work was to look at the factors that contribute to these inequalities, to help raise awareness among stakeholders, governments and policy makers. A literature search was conducted using the Population, Intervention, Comparison, Outcomes (PICO) criteria. The same search strategy was run in Embase and Medline and identified 242 records, which were screened for manual review. Of these, 24 were deemed relevant and were included in this analysis. Most of the 24 publications included in this review originated from the USA (22/24) and involved paediatric patients, teenagers and young adults (61% for children and/or teenagers and young adults versus 39% for adults). The most reported indicator of disparity was socioeconomic status (16/24), followed by geographical location (13/24). All the studies evaluated in this review showed disparities in the access to PBT. As paediatric patients make up a significant proportion of the PBT-eligible patients, equity of access to PBT also raises ethical considerations. Therefore, further research is needed into the equity of access to PBT to reduce the care gap.
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Affiliation(s)
- S Gaito
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK.
| | - M C Aznar
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - N G Burnet
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - A Crellin
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; National Lead Proton Beam Therapy NHS England, UK
| | - A France
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK
| | - D Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida, USA
| | - K J Kirkby
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - S Pan
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - G Whitfield
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - E Smith
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
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5
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Ahmed SK, Keole SR. Proton Therapy in the Adolescent and Young Adult Population. Cancers (Basel) 2023; 15:4269. [PMID: 37686545 PMCID: PMC10487250 DOI: 10.3390/cancers15174269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Adolescent and young adult cancer patients are at high risk of developing radiation-associated side effects after treatment. Proton beam radiation therapy might reduce the risk of these side effects for this population without compromising treatment efficacy. METHODS We review the current literature describing the utility of proton beam radiation therapy in the treatment of central nervous system tumors, sarcomas, breast cancer and Hodgkin lymphoma for the adolescent and young adult cancer population. RESULTS Proton beam radiation therapy has utility for the treatment of certain cancers in the young adult population. Preliminary data suggest reduced radiation dose to normal tissues, which might reduce radiation-associated toxicities. Research is ongoing to further establish the role of proton therapy in this population. CONCLUSION This report highlights the potential utility of proton beam radiation for certain adolescent young adult cancers, especially with reducing radiation doses to organs at risk and thereby potentially lowering risks of certain treatment-associated toxicities.
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Affiliation(s)
- Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA;
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6
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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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7
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Safavi AH, Freeman C, Cheng S, Patel S, Mitera G, Kundapur V, Rutledge R, Tsang DS. Proton Therapy in Canada: Toward Universal Access and Health Equity With a Publicly Funded Facility. Int J Radiat Oncol Biol Phys 2022; 116:394-403. [PMID: 36565727 DOI: 10.1016/j.ijrobp.2022.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 11/17/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Amir H Safavi
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Sylvia Cheng
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Samir Patel
- Division of Radiation Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Gunita Mitera
- Canadian Association of Provincial Cancer Agencies, Toronto, Ontario, Canada
| | - Vijayananda Kundapur
- Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Rob Rutledge
- Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Derek S Tsang
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
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8
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Kowalchuk RO, Corbin KS, Jimenez RB. Particle Therapy for Breast Cancer. Cancers (Basel) 2022; 14:cancers14041066. [PMID: 35205814 PMCID: PMC8870138 DOI: 10.3390/cancers14041066] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 02/05/2023] Open
Abstract
Particle therapy has received increasing attention in the treatment of breast cancer due to its unique physical properties that may enhance patient quality of life and reduce the late effects of therapy. In this review, we will examine the rationale for the use of proton and carbon therapy in the treatment of breast cancer and highlight their potential for sparing normal tissue injury. We will discuss the early dosimetric and clinical studies that have been pursued to date in this domain before focusing on the remaining open questions limiting the widespread adoption of particle therapy.
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Affiliation(s)
- Roman O. Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (R.O.K.); (K.S.C.)
| | - Kimberly S. Corbin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (R.O.K.); (K.S.C.)
| | - Rachel B. Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
- Correspondence:
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9
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Chhabra AM, Choi JI, Hasan S, Press RH, Kabarriti R, Lazarev S, Wolden S, Simone CB. Insurer's Black Box: Inexplicable Barriers to Proton Therapy Access for Young Adults. Int J Radiat Oncol Biol Phys 2021; 110:1538-1539. [PMID: 34273325 DOI: 10.1016/j.ijrobp.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Arpit M Chhabra
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Shaakir Hasan
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Robert H Press
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Rafi Kabarriti
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Stanislav Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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