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Abnormal Neuronal Response to Rectal and Anal Stimuli in Patients Treated for Distal Rectal Cancer With High-Dose Chemoradiotherapy Followed By Watchful Waiting. Dis Colon Rectum 2020; 63:1234-1241. [PMID: 33216494 DOI: 10.1097/dcr.0000000000001610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Watchful waiting in patients with rectal cancer with complete clinical response after chemoradiation therapy has gained increased popularity to avoid morbidity and mortality associated with surgery. Irradiation of the pelvis causes bowel dysfunction, but the effect on anorectal sensory function remains obscure in this patient category. OBJECTIVE The aim of this study was to characterize the sensory pathways of the gut-brain axis in patients with rectal cancer treated solely with chemoradiation therapy (nonconventional regime/dose) compared with healthy volunteers. DESIGN This is an explorative study. SETTINGS Sensory evaluation by rectal distension was performed and cortical evoked potentials were recorded during rapid balloon distensions of the rectum and anal canal. Latencies and amplitudes of cortical evoked potentials were compared, and the relative amplitude of 5 spectral bands from recorded cortical evoked potentials was used as an additional proxy of neuronal processing. PATIENTS Patients with rectal cancer solely with chemoradiation therapy (n = 13) a median of 3.2 years ago (range, 2.3-5.6 y) and healthy volunteers (n = 13) were included. MAIN OUTCOME MEASURES Cortical evoked potentials were measured. RESULTS Patients had 35% lower rectal capacity at a maximum tolerable volume (p = 0.007). We found no differences in rectal cortical evoked potential latencies (p = 0.09) and amplitudes (p = 0.38) between groups. However, spectral analysis of rectal cortical evoked potentials showed a decrease in θ (4-8 Hz) and an increase in β (12-32 Hz) band activity in patients (all p < 0.001). Anal cortical potentials showed an increase in α (8-12 Hz) and β and a decrease in γ (32-70 Hz) band activity (all p < 0.001) in patients compared with healthy volunteers. LIMITATIONS This is an explorative study of limited size. CONCLUSIONS Chemoradiation therapy for distal rectal cancer causes abnormal cortical processing of both anal and rectal sensory input. Such central changes may play a role in symptomatic patients, especially when refractory to local treatments. See Video Abstract at http://links.lww.com/DCR/B270. RESPUESTA NEURONAL ANORMAL A ESTÍMULOS RECTALES Y ANALES, EN PACIENTES TRATADOS POR CÁNCER RECTAL DISTAL, CON QUIMIORRADIOTERAPIA DE DOSIS ALTA, SEGUIDA DE ESPERA VIGILANTE: La espera vigilante en pacientes de cáncer rectal, con respuesta clínica completa después de la quimiorradiación, ha ganado una mayor popularidad en evitar la morbilidad y mortalidad asociadas con la cirugía. La irradiación de la pelvis causa disfunción intestinal, pero el efecto sobre la función sensorial ano-rectal sigue siendo no claro, en esta categoría de pacientes.El objetivo de este estudio, fue caracterizar las vías sensoriales del eje intestino-cerebro en pacientes con cáncer rectal, tratados únicamente con quimiorradiación (régimen / dosis no convencional), en comparación con voluntarios sanos.Es un estudio exploratorio.Se realizó una evaluación sensorial por distensión rectal y se registraron los potenciales evocados corticales, durante las distensiones rápidas con balón en recto y canal anal. Se compararon las latencias y amplitudes de los potenciales evocados corticales, y la amplitud relativa de cinco bandas espectrales registradas, de potenciales evocados corticales, se usaron como proxy adicional del procesamiento neuronal.Pacientes de cáncer rectal, únicamente con terapia de quimiorradiación (n = 13) mediana de 3.2 años (rango 2.3-5.6) y voluntarios sanos (n = 13).Potenciales evocados corticales.Pacientes tuvieron una capacidad rectal menor del 35%, al volumen máximo tolerable (p = 0.007). No encontramos diferencias en las latencias potenciales evocadas corticales rectales (p = 0.09) y amplitudes (p = 0.38) entre los grupos. Sin embargo, el análisis espectral de los potenciales evocados corticales rectales, mostró una disminución en theta (4-8 Hz) aumento en beta (12-32 Hz), y actividad en banda en pacientes (todos p <0.001). Los potenciales evocados corticales anales mostraron un aumento en alfa (8-12 Hz) y beta, disminución en gamma (32-70 Hz), y actividad en banda (todos p <0.001), en pacientes comparados a voluntarios sanos.Este es un estudio exploratorio de tamaño limitado.La quimiorradiación para el cáncer rectal distal, ocasiona procesos corticales sensoriales anormales anales y rectales. Tales cambios centrales pueden desempeñar un papel en pacientes sintomáticos, especialmente cuando son refractarios a tratamientos locales. Consulte Video Resumen en http://links.lww.com/DCR/B270.
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Anuja K, Chowdhury AR, Saha A, Roy S, Rath AK, Kar M, Banerjee B. Radiation-induced DNA damage response and resistance in colorectal cancer stem-like cells. Int J Radiat Biol 2019; 95:667-679. [PMID: 30753097 DOI: 10.1080/09553002.2019.1580401] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: Radiation therapy is an integral part of current treatment modality for colorectal cancer. Recent studies have revealed the presence of cancer stem-like cells (CSCs) population, in different tumors are responsible for therapeutic resistance and disease relapse, including colorectal cancer with poorer survival rate. Hence, characterization of the effect of Ionizing Radiation (IR) in colorectal cancer may serve to explain possible mechanisms. Material and methods: Parental HCT116 and HCT-15 cells and derived colonospheres were irradiated and dose was optimized based on cell survival assay and cell cycle analysis. DNA damage response (DDR) was elucidated by γH2AX foci formation, COMET assay, and ATM, p-ATM, ERCC1 expression post-treatment. The expression level of developmental marker (β-catenin), CSC markers (CD44, KLF4) and telomeric components (TRF2, RAP1, hTERT) were evaluated. Results: We observed cell survival was more in colonospheres post-irradiation and also exhibited decreased γH2AX foci, olive tail moment, increased ERCC1, and p-ATM expression than its parental counterpart which corresponds to efficient DDR. Differential expression of developmental marker, CSC markers, and telomeric components were observed after irradiation. Conclusion: This study highlighted the presence of CSC phenotype in colonospheres having increased DNA repair capacity. Differential expression of developmental marker, CSC markers and telomeric components between parental and colonospheres may contribute in radio-resistance property of CSCs.
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Affiliation(s)
- Kumari Anuja
- a Molecular Stress and Stem Cell Biology Group, School of Biotechnology, KIIT University , Bhubaneswar , India
| | - Amit Roy Chowdhury
- a Molecular Stress and Stem Cell Biology Group, School of Biotechnology, KIIT University , Bhubaneswar , India
| | - Arka Saha
- a Molecular Stress and Stem Cell Biology Group, School of Biotechnology, KIIT University , Bhubaneswar , India
| | - Souvick Roy
- a Molecular Stress and Stem Cell Biology Group, School of Biotechnology, KIIT University , Bhubaneswar , India
| | | | - Madhabananda Kar
- c Department of Surgical Oncology , All India Institute of Medical Sciences (AIIMS) , Bhubaneswar , India
| | - Birendranath Banerjee
- a Molecular Stress and Stem Cell Biology Group, School of Biotechnology, KIIT University , Bhubaneswar , India
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Akyol C, Kuzu MA. Recent surgical advances in colorectal cancer excision: toward optimal outcomes. COLORECTAL CANCER 2016. [DOI: 10.2217/crc-2015-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Colorectal cancer is the third most common cancer affecting both males and females in the western world. Despite all the developments in the current treatment of colorectal cancer, it is still continuing to be an important factor of patient morbidity and mortality worldwide. Surgery is the mainstay of treatment for colorectal cancer. Over the last decade, there have been major changes and developments in the surgical treatment. Understanding the importance of the anatomy, technological advances in minimally invasive surgery and effects of chemoradiotherapy have changed the approaches to colorectal cancer treatment. Today, novel treatment strategies must be targeted not only minimally invasive approaches, but also aiming to increase patients’ quality of life without compromising the oncological principles.
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Affiliation(s)
- Cihangir Akyol
- Department of Surgery, Ankara University School of Medicine, Ankara, Turkey
| | - Mehmet Ayhan Kuzu
- Department of Surgery, Ankara University School of Medicine, Ankara, Turkey
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Current Role of Endoscopic Ultrasonography in Rectal Cancer Evaluation During Multidisciplinary Therapy. CURRENT HEALTH SCIENCES JOURNAL 2015; 41:259-263. [PMID: 30538827 PMCID: PMC6246987 DOI: 10.12865/chsj.41.03.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 03/15/2015] [Indexed: 11/18/2022]
Abstract
We report the case of a patient presenting in the Gastroenterology Department with intermittent rectal bleeding during the past year. A diagnosis of a low rectal adenocarcinoma was based on colonoscopy examination with biopsies, and staging procedures included transrectal endoscopic ultrasonography and magnetic resonance imaging of the abdomen and pelvis (cT2N0M0). Consequently the patient was referred for pre-operative chemoradiotherapy, achieving a complete clinical response as documented by repeated EUS and MRI examinations. Transanal endoscopic microsurgery with pathological assessment of the resected specimen revealed residual adenocarcinoma, highlighting the limitations of current imaging methods, and the constant need of technological improvements.
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Moningi S, Walker AJ, Malayeri AA, Rosati LM, Gearhart SL, Efron JE, Wick EC, Azad NS, Armour EP, Le Y, Herman JM, Shin EJ. Analysis of fiducials implanted during EUS for patients with localized rectal cancer receiving high-dose rate endorectal brachytherapy. Gastrointest Endosc 2015; 81:765-769.e1. [PMID: 25708766 PMCID: PMC4629841 DOI: 10.1016/j.gie.2014.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 11/04/2014] [Indexed: 12/11/2022]
Affiliation(s)
- Shalini Moningi
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amanda J. Walker
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ashkan A. Malayeri
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lauren M. Rosati
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Susan L. Gearhart
- Department of Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathan E. Efron
- Department of Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth C. Wick
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nilofer S. Azad
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elwood P. Armour
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yi Le
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph M. Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eun Ji Shin
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Yang L, Wang W, Hu L, Yang X, Zhong J, Li Z, Yang H, Lei H, Yu H, Liao Z, Zhou F, Xie C, Zhou Y. Telomere-binding protein TPP1 modulates telomere homeostasis and confers radioresistance to human colorectal cancer cells. PLoS One 2013; 8:e81034. [PMID: 24260532 PMCID: PMC3834294 DOI: 10.1371/journal.pone.0081034] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 10/08/2013] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Radiotherapy is one of the major therapeutic strategies in cancer treatment. The telomere-binding protein TPP1 is an important component of the shelterin complex at mammalian telomeres. Our previous reports showed that TPP1 expression was elevated in radioresistant cells, but the exact effects and mechanisms of TPP1 on radiosensitivity is unclear. PRINCIPAL FINDINGS In this study, we found that elevated TPP1 expression significantly correlated with radioresistance and longer telomere length in human colorectal cancer cell lines. Moreover, TPP1 overexpression showed lengthened telomere length and a significant decrease of radiosensitivity to X-rays. TPP1 mediated radioresistance was correlated with a decreased apoptosis rate after IR exposure. Furthermore, TPP1 overexpression showed prolonged G2/M arrest mediated by ATM/ATR-Chk1 signal pathway after IR exposure. Moreover, TPP1 overexpression accelerated the repair kinetics of total DNA damage and telomere dysfunction induced by ionizing radiation. CONCLUSIONS We demonstrated that elevated expressions of TPP1 in human colorectal cancer cells could protect telomere from DNA damage and confer radioresistance. These results suggested that TPP1 may be a potential target in the radiotherapy of colorectal cancer.
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Affiliation(s)
- Lei Yang
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Wenbo Wang
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Liu Hu
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Xiaoxi Yang
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Juan Zhong
- Department of Oncology, the Fifth Hospital of Wuhan, Wuhan, China
| | - Zheng Li
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Hui Yang
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Han Lei
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
- Department of Radiation Oncology & Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Haijun Yu
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
- Department of Radiation Oncology & Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - ZhengKai Liao
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
- Department of Radiation Oncology & Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Fuxiang Zhou
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
- Department of Radiation Oncology & Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Conghua Xie
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
- Department of Radiation Oncology & Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Yunfeng Zhou
- Hubei Cancer Clinical Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, China
- Department of Radiation Oncology & Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, China
- * E-mail:
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Zhang H, Wang DW, Adell G, Sun XF. WRAP53 is an independent prognostic factor in rectal cancer- a study of Swedish clinical trial of preoperative radiotherapy in rectal cancer patients. BMC Cancer 2012; 12:294. [PMID: 22805008 PMCID: PMC3504514 DOI: 10.1186/1471-2407-12-294] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 06/13/2012] [Indexed: 12/11/2022] Open
Abstract
Background Expression of WRAP53 protein has oncogenic properties and it is up regulated in several types of tumors. Methods We examined expression of WRAP53 protein in rectal cancers and analyzed its relationship to the response to preoperative radiotherapy and patient survival. The WRAP53 protein was examined by immunohistochemistry in normal mucosa, primary tumors and lymph node metastases from 143 rectal cancer patients participated in a Swedish clinical trial of preoperative radiotherapy. Results Frequency of WRAP53 protein expression was increased in primary rectal cancer compared to the normal mucosa (p < 0.05). In non-radiotherapy group positive WRAP53 in primary tumors (p = 0.03, RR, 3.73, 95% CI, 1.13-11.89) or metastases (p = 0.01, RR, 4.11, 95% CI, 1.25-13.14), was associated with poor prognosis independently of stages and differentiations. In radiotherapy group, positive WRAP53 in the metastasis correlated with better survival (p = 0.04). An interaction analysis showed that the correlations of WRAP53 with the prognostic significance with and without radiotherapy in the metastasis differed (p = 0.01). In the radiotherapy group, expression of WRAP53 in metastases gave a better outcome (p = 0.02, RR, 0.32, 95% CI, 0.13-0.84), and an interaction analysis showed significance between the two groups (p = 0.01). Conclusion WRAP53 may be a new biomarker used to predict prognosis and to select suitable patients for preoperative radiotherapy.
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Affiliation(s)
- Hong Zhang
- Division of Biomedicine, The Systems Biology Research Center, University of Skövde, Skövde, Sweden
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Salazar R, Navarro M, Losa F, Alonso V, Gallén M, Rivera F, Benavides M, Escudero P, González E, Massutí B, Gómez A, Majem M, Aranda E. Phase II study of preoperative radiotherapy and concomitant weekly intravenous oxaliplatin combined with oral capecitabine for stages II–III rectal cancer. Clin Transl Oncol 2012; 14:592-8. [DOI: 10.1007/s12094-012-0846-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 11/02/2011] [Indexed: 01/03/2023]
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He Z, Subramaniam D, Ramalingam S, Dhar A, Postier RG, Umar S, Zhang Y, Anant S. Honokiol radiosensitizes colorectal cancer cells: enhanced activity in cells with mismatch repair defects. Am J Physiol Gastrointest Liver Physiol 2011; 301:G929-37. [PMID: 21836060 PMCID: PMC3220322 DOI: 10.1152/ajpgi.00159.2011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 08/04/2011] [Indexed: 01/31/2023]
Abstract
DNA mismatch repair is required for correcting any mismatches that are created during replication and recombination, and a defective mismatch repair system contributes to DNA damage-induced growth arrest. The colorectal cancer cell line HCT116 is known to have a mutation in the hMLH1 mismatch repair gene resulting in microsatellite instability and defective mismatch repair. Honokiol is a biphenolic compound that has been used in traditional Chinese medicine for treating various ailments including cancer. This study was designed to test the hypothesis that honokiol enhances the radiosensitivity of cancer cells with mismatch repair defect (HCT116) compared with those that are mismatch repair proficient (HCT116-CH3). We first determined that the combination of honokiol and γ-irradiation treatment resulted in dose-dependent inhibition of proliferation and colony formation in both cell lines. However, the effects were more pronounced in HCT116 cells. Similarly, the combination induced higher levels of apoptosis (caspase 3 activation, Bax to Bcl2 ratio) in the HCT116 cells compared with HCT116-CH3 cells. Cell cycle analyses revealed higher levels of dead cells in HCT116 cells. The combination treatment reduced expression of cyclin A1 and D1 and increased phosphorylated p53 in both cell lines, although there were significantly lower amounts of phosphorylated p53 in the HCT116-CH3 cells, suggesting that high levels of hMLH1 reduce radiosensitivity. These data demonstrate that honokiol is highly effective in radiosensitizing colorectal cancer cells, especially those with a mismatch repair defect.
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Affiliation(s)
- Zhiyun He
- Department of Medicine, Lanzhou University Second Hospital, Gansu Province, China
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Sher DJ. Cost-effectiveness studies in radiation therapy. Expert Rev Pharmacoecon Outcomes Res 2011; 10:567-82. [PMID: 20950072 DOI: 10.1586/erp.10.51] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The field of radiation therapy has made dramatic technical advances over the past 20 years. 3D conformal radiotherapy, intensity-modulated radiation therapy and proton beam therapy have all been developed in an attempt to improve the therapeutic ratio: higher cure rates with lower toxicity. Unfortunately, although the costs of radiation therapy are certainly increasing, it is unclear whether its clinical benefit has also improved. Cost-effectiveness analyses are designed to formally evaluate the cost of a treatment relative to an associated change in quality-adjusted survival. As the cost of oncologic care is increasing, it is critically important to assess the cost-effectiveness of radiation therapy. This article will describe the issues surrounding the delivery and cost of radiation therapy, and it will summarize the work that has been done to evaluate the use of cost-effectiveness in radiation oncology.
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Affiliation(s)
- David J Sher
- Department of Radiation Oncology & Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, MA 02115, USA.
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