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Milano MT, Marks LB, Olch AJ, Yorke ED, Jackson A, Bentzen SM, Constine LS. Comparison of Risks of Late Effects From Radiation Therapy in Children Versus Adults: Insights From the QUANTEC, HyTEC, and PENTEC Efforts. Int J Radiat Oncol Biol Phys 2024; 119:387-400. [PMID: 38069917 DOI: 10.1016/j.ijrobp.2023.08.066] [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: 04/13/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 05/19/2024]
Abstract
Pediatric Normal Tissue Effects in the Clinic (PENTEC) seeks to refine quantitative radiation dose-volume relationships for normal-tissue complication probabilities (NTCPs) in survivors of pediatric cancer. This article summarizes the evolution of PENTEC and compares it with similar adult-focused efforts (eg, Quantitative Analysis of Normal Tissue Effects in the Clinic [QUANTEC] and Hypofractionated Treatment Effects in the Clinic [HyTEC]) with respect to content, oversight, support, scope, and methodology of literature review. It then summarizes key organ-specific findings from PENTEC in an attempt to compare NTCP estimates in children versus adults. In brief, select normal-tissue risks within developing organs and tissues (eg, maldevelopment of musculoskeletal tissue, teeth, breasts, and reproductive organs) are primarily relevant only in children. For some organs and tissues, children appear to have similar (eg, brain for necrosis, optic apparatus, parotid gland, liver), greater (eg, brain for neurocognition, cerebrovascular, breast for lactation), less (ovary), or perhaps slightly less (eg, lung) risks of toxicity versus adults. Similarly, even within the broad pediatric age range (including adolescence), for some endpoints, younger children have greater (eg, hearing and brain for neurocognition) or lesser (eg, ovary, thyroid) risks of radiation-associated toxicities. NTCP comparisons in adults versus children are often confounded by marked differences in treatment paradigms that expose normal tissues to radiation (ie, cancer types, prescribed radiation therapy dose and fields, and chemotherapy agents used). To add to the complexity, it is unclear if age is best analyzed as a continuous variable versus with age groupings (eg, infants, young children, adolescents, young adults, middle-aged adults, older adults). Further work is needed to better understand the complex manner in which age and developmental status affect risk.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York.
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Arthur J Olch
- Radiation Oncology Program, Children's Hospital Los Angeles/Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ellen D Yorke
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Søren M Bentzen
- Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
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Constine LS, Marks LB, Milano MT, Ronckers CM, Jackson A, Hudson MM, Marcus KJ, Hodgson DC, Hua CH, Howell RM, Marples B, Yorke E, Olch A, Bentzen SM. A User's Guide and Summary of Pediatric Normal Tissue Effects in the Clinic (PENTEC): Radiation Dose-Volume Response for Adverse Effects After Childhood Cancer Therapy and Future Directions. Int J Radiat Oncol Biol Phys 2024; 119:321-337. [PMID: 37999712 DOI: 10.1016/j.ijrobp.2023.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 11/25/2023]
Abstract
Pediatric Normal Tissue Effects in the Clinic (PENTEC) is an international multidisciplinary effort that aims to summarize normal-tissue toxicity risks based on published dose-volume data from studies of children and adolescents treated with radiation therapy (RT) for cancer. With recognition that children are uniquely vulnerable to treatment-related toxic effects, our mission and challenge was to assemble our group of physicians (radiation and pediatric oncologists, subspecialists), physicists with clinical and modeling expertise, epidemiologists, and other scientists to develop evidence-based radiation dosimetric guidelines, as affected by developmental status and other factors (eg, other cancer therapies and host factors). These quantitative toxicity risk estimates could serve to inform RT planning and thereby improve outcomes. Tandem goals included the description of relevant medical physics issues specific to pediatric RT and the proposal of dose-volume outcome reporting standards to inform future studies. We created 19 organ-specific task forces and methodology to unravel the wealth of data from heterogeneous published studies. This report provides a high-level summary of PENTEC's genesis, methods, key findings, and associated concepts that affected our work and an explanation of how our findings may be interpreted and applied in the clinic. We acknowledge our predecessors in these efforts, and we pay homage to the children whose lives informed us and to future generations who we hope will benefit from this additional step in our path forward.
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Affiliation(s)
- Louis S Constine
- Departments of Radiation Oncology and; Pediatrics, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York.
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Cécile M Ronckers
- Division of Childhood Cancer Epidemiology (EpiKiK) and the German Childhood Cancer Registry (DKKR), Johannes Gutenberg University of Mainz, Germany
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa M Hudson
- Department of Oncology, Division of Cancer Survivorship, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Karen J Marcus
- Department of Radiation Oncology, Dana Farber/ Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - David C Hodgson
- Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Rebecca M Howell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | | | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Arthur Olch
- Department of Radiation Oncology, University of Southern California and Children's Hospital of Los Angeles, Los Angeles, California
| | - Soren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland
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Salerno KE, Ermoian RP. Pediatric Normal Tissue Effects in the Clinic (PENTEC): An Extraordinary Step Forward for Pediatric Radiation Oncology. Int J Radiat Oncol Biol Phys 2024; 119:313-314. [PMID: 38760113 DOI: 10.1016/j.ijrobp.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 05/19/2024]
Affiliation(s)
- Kilian E Salerno
- Radiation Oncology Branch, National Cancer Institute, Bethesda, Maryland
| | - Ralph P Ermoian
- Department of Radiation Oncology, University of Washington, Seattle, Washington.
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Hua CH, Bentzen SM, Li Y, Milano MT, Rancati T, Marks LB, Constine LS, Yorke ED, Jackson A. Improving Pediatric Normal Tissue Radiation Dose-Response Modeling in Children With Cancer: A PENTEC Initiative. Int J Radiat Oncol Biol Phys 2024; 119:369-386. [PMID: 38276939 DOI: 10.1016/j.ijrobp.2023.11.038] [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: 07/14/2023] [Revised: 11/07/2023] [Accepted: 11/19/2023] [Indexed: 01/27/2024]
Abstract
The development of normal tissue radiation dose-response models for children with cancer has been challenged by many factors, including small sample sizes; the long length of follow-up needed to observe some toxicities; the continuing occurrence of events beyond the time of assessment; the often complex relationship between age at treatment, normal tissue developmental dynamics, and age at assessment; and the need to use retrospective dosimetry. Meta-analyses of published pediatric outcome studies face additional obstacles of incomplete reporting of critical dosimetric, clinical, and statistical information. This report describes general methods used to address some of the pediatric modeling issues. It highlights previous single- and multi-institutional pediatric dose-response studies and summarizes how each PENTEC taskforce addressed the challenges and limitations of the reviewed publications in constructing, when possible, organ-specific dose-effect models.
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Affiliation(s)
- Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.
| | - Søren M Bentzen
- Department of Epidemiology and Public Health, Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Yimei Li
- Department of Biostatics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Tiziana Rancati
- Data Science Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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Jackson A, Hua CH, Olch A, Yorke ED, Rancati T, Milano MT, Constine LS, Marks LB, Bentzen SM. Reporting Standards for Complication Studies of Radiation Therapy for Pediatric Cancer: Lessons From PENTEC. Int J Radiat Oncol Biol Phys 2024; 119:697-707. [PMID: 38760117 DOI: 10.1016/j.ijrobp.2024.02.018] [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: 07/08/2023] [Revised: 01/14/2024] [Accepted: 02/08/2024] [Indexed: 05/19/2024]
Abstract
The major aim of Pediatric Normal Tissue Effects in the Clinic (PENTEC) was to synthesize quantitative published dose/-volume/toxicity data in pediatric radiation therapy. Such systematic reviews are often challenging because of the lack of standardization and difficulty of reporting outcomes, clinical factors, and treatment details in journal articles. This has clinical consequences: optimization of treatment plans must balance between the risks of toxicity and local failure; counseling patients and their parents requires knowledge of the excess risks encountered after a specific treatment. Studies addressing outcomes after pediatric radiation therapy are particularly challenging because: (a) survivors may live for decades after treatment, and the latency time to toxicity can be very long; (b) children's maturation can be affected by radiation, depending on the developmental status of the organs involved at time of treatment; and (c) treatment regimens frequently involve chemotherapies, possibly modifying and adding to the toxicity of radiation. Here we discuss: basic reporting strategies to account for the actuarial nature of the complications; the reporting of modeling of abnormal development; and the need for standardized, comprehensively reported data sets and multivariate models (ie, accounting for the simultaneous effects of radiation dose, age, developmental status at time of treatment, and chemotherapy dose). We encourage the use of tools that facilitate comprehensive reporting, for example, electronic supplements for journal articles. Finally, we stress the need for clinicians to be able to trust artificial intelligence models of outcome of radiation therapy, which requires transparency, rigor, reproducibility, and comprehensive reporting. Adopting the reporting methods discussed here and in the individual PENTEC articles will increase the clinical and scientific usefulness of individual reports and associated pooled analyses.
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Affiliation(s)
- Andrew Jackson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York.
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Arthur Olch
- Radiation Oncology Department, University of Southern California and Children's Hospital, Los Angeles, California
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Tiziana Rancati
- Data Science Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York; Pediatrics, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Soren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland
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