Discontinuation of radiation treatment among medicaid-enrolled women with local and regional stage breast cancer

Discontinuation of Palliative Brain Radiotherapy in Patients with Brain Metastases: A Case-Control Study

Background: Discontinuation of radiotherapy is rarely discussed in the scientific literature. The goal of this study was, therefore, to estimate the frequency of and reasons for treatment discontinuations in patients receiving radiotherapy for brain metastases from solid tumors and to identify factors predicting said discontinuations. Methods: All patients treated for brain metastases from solid tumors between 2010 and 2020 at our institution were retrospectively reviewed. In addition to collecting relevant patient characteristics, the Recursive Partitioning Analysis (RPA) and disease-specific Graded Prognostic Assessment (GPA) groups for each patient were calculated to assess the performance of these scores in predicting treatment discontinuations. Results: Out of 468 patients who underwent cranial radiotherapy, 35 treatments (7.5%) were discontinued. The most frequent reason was clinical deterioration, which was documented in 26 (74.3%) of discontinued treatments. Patients whose radiotherapy was discontinued had, on average, more leptomeningeal disease (20.0% vs. 12.6%), worse ECOG performance status (mean ECOG performance status 1.86 vs. 1.39), and more uncontrolled extracranial metastases (85.3% vs. 70.8%). The frequencies of treatment discontinuation increased with worse prognosis and differed significantly across RPA groups (p = 0.037) but not across GPA groups (p = 0.612). Conclusions: Treatment discontinuation occurred in 7.5% of cases, mostly due to clinical deterioration. Poor performance status, as well as more advanced disease and, in turn, poor prognosis, were associated with higher discontinuation rates.

Predictors of Whole Breast Radiation Therapy Completion in Early Stage Breast Cancer Following Lumpectomy

BACKGROUND

Whole breast radiation therapy (RT) has become standard of care in early stage breast cancer treatment following lumpectomy. Predictors of RT completion have been sparsely studied, with no previous nationwide examination of the impact of fractionation regimen on completion rate.

PATIENTS AND METHODS

The National Cancer Database identified patients with early stage breast cancer having undergone lumpectomy and RT from 2004 through 2015. Fraction size of 1.8-2.0 Gray (Gy) was defined as standard fractionation (SFRT); 2.66-2.70 Gy/fraction as hypofractionation (HFRT). RT completion was defined as receipt of at least 46 Gy for SFRT and 40 Gy for HFRT. A multivariable logistic regression model characterized RT completion predictors.

RESULTS

A total of 100,734 patients were identified where fraction size could be reliably characterized as above; more than 87% completed RT. Of these, 66.8% received SFRT, yet HFRT use significantly increased over time (5.2% increase/year; P < .0001). RT completion rates were significantly greater following HFRT (99.3%) versus SFRT (79.7%); patients receiving SFRT had higher odds of not completing RT (odds ratio, 41.5; 95% confidence interval, 36.6-47.1; P < .0001). Multivariable analysis revealed that African-American and Caucasian patients treated with SFRT versus HFRT had 22 and 43 times the odds of not completing RT, respectively (P < .0001).

CONCLUSIONS

SFRT remained the majority of RT fractionation in the studied time period, although HFRT use has increased over time. Patients residing > 10 miles from a treatment facility or of African-American race had lower odds of completing RT, as were patients treated with SFRT versus HFRT. These findings suggest compliance advantages of HFRT for patients with early stage breast cancer having undergone lumpectomy.

Appropriate treatment receipt after breast-conserving surgery

Background

Breast-conserving surgery (bcs) and radiation therapy (rt) are the standard of care for early breast cancer, although some women receive ipsilateral mastectomy or adjuvant tamoxifen, both of which can be appropriate alternatives to rt. Objectives of the present study were to determine the proportion of women who are treated appropriately after bcs and to identify factors associated with non-receipt of rt.

Methods

This retrospective cohort study used Ontario data linked at the Institute for Clinical and Evaluative Sciences to examine 33,718 patients who received bcs during 2004-2010. Primary outcome was rt receipt. The ipsilateral mastectomy rate and patient, surgeon, and setting variables were measured.

Results

Of the study patients, 86.1% received either rt or completion mastectomy; in the cohort less than 70 years of age, 90.8% received rt or completion mastectomy. Among patients less than 70 years of age, 3 risk factors for non-receipt of rt were identified: age less than 46 years, treatment in a non-academic institution, and earlier year of initial bcs. Additionally, in the overall cohort, rt non-receipt was associated with high comorbidity, more than 40 km to the cancer centre, income quintile, and breast care specialization.

Conclusions

In Ontario, 90.8% of patients less than 70 years of age are appropriately treated for early breast cancer; approximately 1 in 10 do not receive rt or completion mastectomy. Based on those findings, women less than 46 years of age might be at increased risk of recurrence and death because of incomplete treatment. It also appears that academic centres more effectively treat breast cancer; however, breast cancer care appears to be improving over time in Ontario.

A unique hypofractionated radiotherapy schedule with 51.3 Gy in 18 fractions three times per week for early breast cancer: outcomes including local control, acute and late skin toxicity

AIM

Evaluation of local control and acute and late toxicity regarding a hypofractionated RT schedule for breast cancer patients.

METHODS AND MATERIALS

Between October 2007 and October 2009, 80 women with early breast cancer were treated by 42.75 Gy in 15 fractions over 5 weeks. This treatment involved three fractions per week (Monday-Wednesday-Friday). All patients received an additional boost dose to the tumor bed of 8.55 Gy in 3 fractions using 6 MV photons. The primary endpoint included any local recurrence in the treated breast. Secondary endpoint included acute and late radiation skin toxicity. The median follow-up time was 63 months (range 60-72). Radiation toxicity was graded according the RTOG/EORTC criteria.

RESULTS

Neither local nor distant recurrence was noted in any patient during this 3-year follow-up. Grade 0, 1, 2 acute skin toxicity was observed in 56/80 (70.0 %), in 19/80 (23.8 %) and in 5/80 (6.3 %), respectively. Three months post-RT, toxicity grades 0, 1, 2 skin toxicity were 64/80 (80 %), 14/80 (17.5 %) and 2/80 (2.5 %), respectively. Late toxicity as grade 0, 1 was observed in 72/80 (90.0 %) and in 8/80 (10.0 %), respectively, 6 months post-RT, whereas after 1 year they were 78/80 (97.5 %) and 2/80 (2.5 %), respectively.

CONCLUSIONS

Preliminary results regarding skin reactions, cosmetic appearance and local control are consistent with published data that support the use of shorter fractionation schedules in early breast cancer patients after breast conservative surgery. Longer follow-up and a randomized prospective study stand in need for the extraction of safe conclusions.

Demographic risk factors impacting timely radiation therapy completion after breast conserving surgery

BACKGROUND

Radiotherapy completion (RTC) is critical to successful breast conserving treatment. Our aim was to identify patient groups at greatest risk of not achieving timely radiotherapy completion (TRTC) in an urban setting.

METHODS

This observational cohort study used hospital registry data from 2004 to 2010 for female stage I and II breast conserving treatment patients to assess predictors of RTC and TRTC, defined as RTC of 35 to 49 days.

RESULTS

Two hundred sixty-one patients were analyzed. There was no difference in mean days to RTC by ethnicity (black 46.8, white 46.4, Hispanic 48.1 days, P = .75) or total RTC (black 88.2%, white 97.9%, Hispanic 93.3%, P = .09). However, a substantial difference was seen in TRTC by ethnicity (black 51.8%, white 79.2%, Hispanic 57.8%, P = .03). Multivariate logistic regression analysis of failure to achieve TRTC found associations with black race (odds ratio [OR] 2.67), Medicare (OR 3.46), Medicaid (OR 2.19), and age less than 50 years (OR 4.13).

CONCLUSIONS

This study demonstrates high overall percentage RTC but demonstrates disparities in TRTC. Those at greatest risk of unsuccessful TRTC were younger, Medicare or Medicaid insured, and black race.

Quality assurance in radiotherapy: analysis of the causes of not starting or early radiotherapy withdrawal

BACKGROUND

The aim of this study was to analyse the reasons for not starting or for early of radiotherapy at the Radiation Oncology Department.

METHODS

All radiotherapy treatments from March 2010 to February 2012 were included. Early withdrawals from treatment those that never started recorded. Clinical, demographic and dosimetric variables were also noted.

RESULTS

From a total of 3250 patients treated and reviewed, 121 (4%) did not start or complete the planned treatment. Of those, 63 (52%) did not receive any radiotherapy fraction and 58 (48%) did not complete the course, 74% were male and 26% were female. The mean age was 67 ± 13 years. The most common primary tumour was lung (28%), followed by rectum (16%). The aim of treatment was 62% radical and 38% palliative, 44% of patients had metastases; the most common metastatic site was bone, followed by brain. In 38% of cases (46 patients) radiotherapy was administered concomitantly with chemotherapy (10 cases (22%) were rectal cancers). The most common reason for not beginning or for early withdrawal of treatment was clinical progression (58/121, 48%). Of those, 43% died (52/121), 35 of them because of the progression of the disease and 17 from other causes. Incomplete treatment regimens were due to toxicity (12/121 (10%), of which 10 patients underwent concomitant chemotherapy for rectal cancer).

CONCLUSIONS

The number of patients who did not complete their course of treatment is low, which shows good judgement in indications and patient selection. The most common reason for incomplete treatments was clinical progression. Rectal cancer treated with concomitant chemotherapy was the most frequent reason of the interruption of radiotherapy for toxicity.

Intraoperative radiation therapy in early breast cancer using a linear accelerator outside of the operative suite: an "image-guided" approach

PURPOSE

To present local control, complications, and cosmetic outcomes of intraoperative radiation therapy (IORT) for early breast cancer, as well as technical aspects related to the use of a nondedicated linear accelerator.

METHODS AND MATERIALS

This prospective trial began in May of 2004. Eligibility criteria were biopsy-proven breast-infiltrating ductal carcinoma, age >40 years, tumor <3 cm, and cN0. Exclusion criteria were in situ or lobular types, multicentricity, skin invasion, any contraindication for surgery and/or radiation therapy, sentinel lymph node involvement, metastasis, or another malignancy. Patients underwent classic quadrantectomy with intraoperative sentinel lymph node and margins evaluation. If both free, the patient was transferred from operative suite to linear accelerator room, and IORT was delivered (21 Gy). Primary endpoint: local recurrence (LR); secondary endpoints: toxicities and aesthetics. Quality assurance involved using a customized shield for chest wall protection, applying procedures to minimize infection caused by patient transportation, and using portal films to check collimator-shield alignment.

RESULTS

A total of 152 patients were included, with at least 1 year follow-up. Median age (range) was 58.3 (40-85.4) years, and median follow-up time was 50.7 (12-110.5) months. The likelihood of 5-year local recurrence was 3.7%. There were 3 deaths, 2 of which were cancer related. The Kaplan-Meier 5-year actuarial estimates of overall, disease-free, and local recurrence-free survivals were 97.8%, 92.5%, and 96.3%, respectively. The overall incidences of acute and late toxicities were 12.5% and 29.6%, respectively. Excellent, good, fair, and bad cosmetic results were observed in 76.9%, 15.8%, 4.3%, and 2.8% of patients, respectively. Most treatments were performed with a 5-cm collimator, and in 39.8% of the patients the electron-beam energy used was ≥12 MeV. All patients underwent portal film evaluation, and the shielding was repositioned in 39.9% of cases. No infection or anesthesia complications were observed.

CONCLUSIONS

Local control with IORT was adequate, with low complication rates and good cosmetic outcomes. More than one-third of patients benefited from the "image-guidance" approach, and almost 40% benefited from the option of higher electron beam energies.

A Population-Based Observational Study of First-Course Treatment and Survival for Adolescent and Young Adult Females with Breast Cancer

PURPOSE

Young age at breast cancer diagnosis is associated with poor survival. However, little is known about factors associated with first-course treatment receipt or survival among adolescent and young adult (AYA) females aged 15-39 years.

METHODS

Data regarding 19,906 eligible AYA breast cancers diagnosed in California during 1992-2009 were obtained from the population-based California Cancer Registry. Multivariable logistic regression was used to evaluate clinical and sociodemographic differences in treatment receipt. Multivariable Cox proportional hazards regression was used to examine differences in survival by initial treatment, and by patient and tumor characteristics.

RESULTS

Black and Hispanic AYAs diagnosed with in situ or stages I-III breast cancer were more likely than White AYAs to receive breast-conserving surgery (BCS) without radiation; Asian and Hispanic AYAs were more likely than Whites to receive mastectomy. Women in lower socioeconomic status (SES) neighborhoods were more likely to omit radiation after BCS, more likely to receive mastectomy, and less likely to receive chemotherapy, compared to those in higher SES neighborhoods. Among patients with invasive disease, survival improved an average of 5% per year during 1992-2009. AYAs who received BCS with radiation experienced better survival than other surgery/radiation options. Black AYAs had poorer survival than Whites. AYAs who resided in higher SES neighborhoods had better survival.

CONCLUSIONS

Treatment receipt among AYAs with breast cancer varied by race/ethnicity and neighborhood SES. Poor survival for Black AYAs and AYAs living in low SES neighborhoods in models adjusted for treatment receipt suggests that factors other than treatment may also be important to disease outcome.

Racial disparities in travel time to radiotherapy facilities in the Atlanta metropolitan area

Low-income women with breast cancer who rely on public transportation may have difficulty in completing recommended radiation therapy due to inadequate access to radiation facilities. Using a geographic information system (GIS) and network analysis we quantified spatial accessibility to radiation treatment facilities in the Atlanta, Georgia metropolitan area. We built a transportation network model that included all bus and rail routes and stops, system transfers and walk and wait times experienced by public transportation system travelers. We also built a private transportation network to model travel times by automobile. We calculated travel times to radiation therapy facilities via public and private transportation from a population-weighted center of each census tract located within the study area. We broadly grouped the tracts by low, medium and high household access to a private vehicle and by race. Facility service areas were created using the network model to map the extent of areal coverage at specified travel times (30, 45 and 60 min) for both public and private modes of transportation. The median public transportation travel time to the nearest radiotherapy facility was 56 min vs. approximately 8 min by private vehicle. We found that majority black census tracts had longer public transportation travel times than white tracts across all categories of vehicle access and that 39% of women in the study area had longer than 1 h of public transportation travel time to the nearest facility. In addition, service area analyses identified locations where the travel time barriers are the greatest. Spatial inaccessibility, especially for women who must use public transportation, is one of the barriers they face in receiving optimal treatment.

A checklist for ascertaining study cohorts in oncology health services research using secondary data: report of the ISPOR oncology good outcomes research practices working group

OBJECTIVES

The ISPOR Oncology Special Interest Group formed a working group at the end of 2010 to develop standards for conducting oncology health services research using secondary data. The first mission of the group was to develop a checklist focused on issues specific to selection of a sample of oncology patients using a secondary data source.

METHODS

A systematic review of the published literature from 2006 to 2010 was conducted to characterize the use of secondary data sources in oncology and inform the leadership of the working group prior to the construction of the checklist. A draft checklist was subsequently presented to the ISPOR membership in 2011 with subsequent feedback from the larger Oncology Special Interest Group also incorporated into the final checklist.

RESULTS

The checklist includes six elements: identification of the cancer to be studied, selection of an appropriate data source, evaluation of the applicability of published algorithms, development of custom algorithms (if needed), validation of the custom algorithm, and reporting and discussions of the ascertainment criteria. The checklist was intended to be applicable to various types of secondary data sources, including cancer registries, claims databases, electronic medical records, and others.

CONCLUSIONS

This checklist makes two important contributions to oncology health services research. First, it can assist decision makers and reviewers in evaluating the quality of studies using secondary data. Second, it highlights methodological issues to be considered when researchers are constructing a study cohort from a secondary data source.

Black-white differences in receipt and completion of adjuvant chemotherapy among breast cancer patients in a rural region of the US

Recent breast cancer treatment studies conducted in large urban settings have reported racial disparities in the appropriate use of adjuvant chemotherapy. This article presents the first focused evaluation of black-white differences in receipt and completion of chemotherapy for breast cancer in a primarily rural region of the United States. We performed chart abstraction on initial therapy received by 868 women diagnosed with Stages I, IIA, IIB, or IIIA breast cancer in 2001-2003 in southwest Georgia (SWGA). For chemotherapy, information collected included treatment plan, dates of delivery, concordance between therapy planned and received, and date and reasons for end of treatment. The patient's age at diagnosis, race, marital status, insurance coverage, hormone receptor status, comorbidities, socioeconomic status, urban/rural status, treatment site, and distance to the site were also collected. Following univariate analyses, we used multivariable logistic regression modeling to examine the impact of race on the likelihood of (1) receiving chemotherapy and (2) completing planned chemotherapy. For patients terminating chemotherapy prematurely, the reasons were documented. The results showed that the unadjusted black-white difference in receipt of chemotherapy (48.3 vs. 36.0%) was significant, but in the multivariable analysis the black-white odds ratio (OR = 1.18) was not. While the unadjusted black-white difference (92.0 vs. 87.8%) in completing chemotherapy was not significant, in multivariable models black race was positively associated with completing care (p ranging from 0.032 to 0.087 and OR, correspondingly, from 2.16 to 2.64). The impact of race on completing chemotherapy was influenced by marital status, with a significant black-white difference for patients not married (OR = 4.67), but no difference for those married (OR = 1.06). We find compelling racial differences in this largely rural region-with black breast cancer patients receiving or completing chemotherapy at rates that equal or exceed white patients. Further investigation is warranted, both in SWGA and in other rural regions.

Biologically effective dose and breast cancer conservative treatment: is duration of radiation therapy really important?

To evaluate if biologically effective dose (BED), and in particular the duration of radiation treatment, has an effect on local relapse risk. Between January 2000 and December 2008 a total of 762 patients with T1-2 N0/+ breast cancer was treated with breast-conserving surgery and radiotherapy, with and without hormone therapy and chemotherapy. Adjuvant radiation therapy was administered to a total dose of 60-66 Gy in 30-33 fractions. The computed BEDs were divided in four groups: <43.1, 43.1-44.9, 45.0-46.1, and >46.1 Gy (A-D, respectively). Kaplan-Meier method was used to calculate local relapse rates. Cox regression method was used to identify prognostic factors of local relapse. Evaluated variables were age, tumor histology, tumor size, surgical margin status, axillary nodal status, tumor grading, adjuvant therapies, adjuvant chemotherapy alone, adjuvant hormone therapy alone, adjuvant anthracyclines, and BEDs values. 8-year local relapse rates were 18.0% for group A, 8.5% for group B, 4.6% for group C, and 2.7% for group D (P=0.008). Multivariate Cox regression analysis showed that BEDs values were associated with higher local relapse risk (P=0.001). In our study, a prolongation of radiotherapy treatment, intended as a lower BED value, after breast-conserving surgery is associated with an increased risk of local relapse. Considering the wide range of results published in other studies, hypofractionation for breast cancer should be considered, at the moment, feasible in selected patients.