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Zaorsky NG, Ahmed AA, Zhu J, Yoo SK, Fuller CD, Thomas CR, Choi M, Holliday EB. Industry Funding Is Correlated With Publication Productivity of US Academic Radiation Oncologists. J Am Coll Radiol 2018; 16:244-251. [PMID: 30219342 DOI: 10.1016/j.jacr.2018.07.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 07/11/2018] [Accepted: 07/20/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE Industry payments to physicians are financial conflicts of interest and may influence research findings and medical decisions. We aim to (1) characterize industry payments within radiation oncology; and (2) explore the potential correlation between receiving disclosed industry payments and academic productivity. MATERIALS/METHODS CMS database was used to extract 2015 industry payments. For academic radiation oncologists, research productivity was characterized by h- and m-indices, as well as receipt of National Institutes of Health (NIH) funding, which is not an industry payment. Logistic regression models were used to determine whether publication metrics (m-index, h-index) and other study characteristics such as gender, PhD status, NIH institution funding status, were associated with the endpoints, research and general payments. Associations between the amount of payments (if any) and publication metrics were further studied using linear regression models. RESULTS A total of 22,543 individual payments totaling $25,532,482 to 2,995 radiation oncologists were included. Among the 1,189 academic radiation oncologists, 75% received less than $167; on the other hand, 10 (<1%) individuals received $6,425,728 (51%) of payments. On multiple logistic regression, research payments were significantly associated with the m-index, odds ratio 2.86 (95% confidence interval, 1.84-4.45, p-value <0.0001); as well as with the h-index, odds ratio 1.03 (95% confidence interval, 1.01-1.05, p-value <0.0001). The linear regression model shows that both m-index and h-index were significantly positively associated with the amount of general payments (p-values <0.0001). CONCLUSION There is an association between disclosed payment from the industry and increased individual research productivity metrics. Further research to find the cause behind this association is warranted.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania.
| | - Awad A Ahmed
- Department of Radiation Oncology, University of Miami, Miami, Florida
| | - Junjia Zhu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Stella K Yoo
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Charles R Thomas
- Department of Radiation Medicine, Oregon Health & Science University Knight Cancer Institute, Portland, Oregon
| | - Mehee Choi
- Department of Radiation Oncology, Loyola University Chicago, Chicago, Illinois
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Kothari G, Loblaw A, Tree AC, van As NJ, Moghanaki D, Lo SS, Ost P, Siva S. Stereotactic Body Radiotherapy for Primary Prostate Cancer. Technol Cancer Res Treat 2018; 17:1533033818789633. [PMID: 30064301 PMCID: PMC6069023 DOI: 10.1177/1533033818789633] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/07/2018] [Accepted: 06/14/2018] [Indexed: 12/25/2022] Open
Abstract
Prostate cancer is the most common non-cutaneous cancer in males. There are a number of options for patients with localized early stage disease, including active surveillance for low-risk disease, surgery, brachytherapy, and external beam radiotherapy. Increasingly, external beam radiotherapy, in the form of dose-escalated and moderately hypofractionated regimens, is being utilized in prostate cancer, with randomized evidence to support their use. Stereotactic body radiotherapy, which is a form of extreme hypofractionation, delivered with high precision and conformality typically over 1 to 5 fractions, offers a more contemporary approach with several advantages including being non-invasive, cost-effective, convenient for patients, and potentially improving patient access. In fact, one study has estimated that if half of the patients currently eligible for conventional fractionated radiotherapy in the United States were treated instead with stereotactic body radiotherapy, this would result in a total cost savings of US$250 million per year. There is also a strong radiobiological rationale to support its use, with prostate cancer believed to have a low α/β ratio and therefore being preferentially sensitive to larger fraction sizes. To date, there are no published randomized trials reporting on the comparative efficacy of stereotactic body radiotherapy compared to alternative treatment modalities, although multiple randomized trials are currently accruing. Yet, early results from the randomized phase III study of HYPOfractionated RadioTherapy of intermediate risk localized Prostate Cancer (HYPO-RT-PC) trial, as well as multiple single-arm phase I/II trials, indicate low rates of late adverse effects with this approach. In patients with low- to intermediate-risk disease, excellent biochemical relapse-free survival outcomes have been reported, albeit with relatively short median follow-up times. These promising early results, coupled with the enormous potential cost savings and implications for resource availability, suggest that stereotactic body radiotherapy will take center stage in the treatment of prostate cancer in the years to come.
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Affiliation(s)
- Gargi Kothari
- Royal Marsden NHS Foundation Trust, London, United Kingdom
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Loblaw
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Alison C. Tree
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Drew Moghanaki
- Hunter Holmes McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Simon S. Lo
- University of Washington School of Medicine, Seattle, WA, USA
| | - Piet Ost
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Peter MacCallum Cancer Center, Melbourne, Victoria, Australia
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Ragab O, Banerjee R, Park SJ, Patel S, Zhang M, Wang J, Velez M, Demanes DJ, Kamrava M. Comparison of patient-reported acute urinary and sexual toxicity scores in a 6- versus 2-fraction course of high-dose-rate prostate brachytherapy monotherapy. J Med Imaging Radiat Oncol 2017; 62:109-115. [PMID: 28856847 DOI: 10.1111/1754-9485.12648] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/22/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION To identify differences in acute urinary and sexual toxicity between a 6-fraction and 2-fraction high-dose-rate brachytherapy monotherapy regimen and correlate dosimetric constraints to short-term toxicity. METHODS A single institution retrospective study of 116 men with prostate cancer treated with HDR monotherapy from 2010 to 2015 was conducted. Eighty-one men had 7.25 Gy × 6-fractions and 35 men had 13.5 Gy × 2-fractions. Patients had two CT-planned implants spaced 1-2 weeks apart. Patient baseline characteristics, International Prostate Symptom Scores (IPSS) and Sexual Health Inventory for Men (SHIM) scores were collected pre-treatment and 3, 6 and 12 months post-implantation. Mixed effect modelling was undertaken to compare baseline, 1-6 month and 7-12 month scores between groups. Poisson regression analysis was performed to correlate dosimetric constraints with acute toxicity. RESULTS There was no difference between baseline and post-implantation IPSS scores between 6-fraction and 2-fraction groups. SHIM scores for men treated with 6-fractions had a steeper decline at 1-6 months, but resolved at 7-12 months. Pre-treatment alpha-blocker use correlated with worse short-term acute urinary toxicity. Worsened SHIM score correlated with increasing age, diabetes mellitus and androgen-deprivation therapy. In a dosimetric analysis of outcomes, prostate V150 dose and bladder wall (D01.cc, D1cc, D2cc) dose correlated with increased IPSS score. CONCLUSION No increased acute genitourinary or sexual dysfunction has been observed in men when transitioning from 6-fraction to 2-fraction HDR monotherapy. A dosimetric correlation was found between the V150 and bladder wall doses for acute urinary toxicity. Future research should continue to standardize and validate dose constraints for prostate HDR monotherapy patients.
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Affiliation(s)
- Omar Ragab
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, California, USA
| | - Robyn Banerjee
- Department of Radiation Oncology, Tom Baker Cancer Center, Calgary, Alberta, USA
| | - Sang-June Park
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Shyamal Patel
- Department of Radiation Oncology, University of Arizona Cancer Center at Dignity Health, Phoenix, Arizona, USA
| | - Mingle Zhang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Jason Wang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Maria Velez
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - David Jeffrey Demanes
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Mitchell Kamrava
- Department of Radiation Oncology, Samuel Oschin Cancer Center, Cedars Sinai Medical Center, Los Angeles, California, USA
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Zaorsky NG, Davis BJ, Nguyen PL, Showalter TN, Hoskin PJ, Yoshioka Y, Morton GC, Horwitz EM. The evolution of brachytherapy for prostate cancer. Nat Rev Urol 2017; 14:415-439. [PMID: 28664931 PMCID: PMC7542347 DOI: 10.1038/nrurol.2017.76] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Brachytherapy (BT), using low-dose-rate (LDR) permanent seed implantation or high-dose-rate (HDR) temporary source implantation, is an acceptable treatment option for select patients with prostate cancer of any risk group. The benefits of HDR-BT over LDR-BT include the ability to use the same source for other cancers, lower operator dependence, and - typically - fewer acute irritative symptoms. By contrast, the benefits of LDR-BT include more favourable scheduling logistics, lower initial capital equipment costs, no need for a shielded room, completion in a single implant, and more robust data from clinical trials. Prospective reports comparing HDR-BT and LDR-BT to each other or to other treatment options (such as external beam radiotherapy (EBRT) or surgery) suggest similar outcomes. The 5-year freedom from biochemical failure rates for patients with low-risk, intermediate-risk, and high-risk disease are >85%, 69-97%, and 63-80%, respectively. Brachytherapy with EBRT (versus brachytherapy alone) is an appropriate approach in select patients with intermediate-risk and high-risk disease. The 10-year rates of overall survival, distant metastasis, and cancer-specific mortality are >85%, <10%, and <5%, respectively. Grade 3-4 toxicities associated with HDR-BT and LDR-BT are rare, at <4% in most series, and quality of life is improved in patients who receive brachytherapy compared with those who undergo surgery.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111-2497, USA
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Charlton Bldg/Desk R - SL, Rochester, Minnesota 5590, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital, 75 Francis St BWH. Radiation Oncology, Boston, Massachusetts 02115, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, 1240 Lee St, Charlottesville, Virginia 22908, USA
| | - Peter J Hoskin
- Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Gerard C Morton
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111-2497, USA
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Zaorsky NG, Shaikh T, Ruth K, Sharda P, Hayes SB, Sobczak ML, Hallman MA, Smaldone MC, Chen DYT, Horwitz EM. Prostate Cancer Patients With Unmanaged Diabetes or Receiving Insulin Experience Inferior Outcomes and Toxicities After Treatment With Radiation Therapy. Clin Genitourin Cancer 2016; 15:326-335.e3. [PMID: 27789181 DOI: 10.1016/j.clgc.2016.08.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/22/2016] [Accepted: 08/26/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The purpose of the study was to determine the effect of type 2 diabetes mellitus (T2DM) on outcomes and toxicities among men with localized prostate cancer receiving definitive radiation therapy. PATIENTS AND METHODS We performed a retrospective review of 3217 patients, from 1998 to 2013, subdivided into 5 subgroups: (I) no T2DM; (II) T2DM receiving oral antihyperglycemic agent that contains metformin, no insulin; (III) T2DM receiving nonmetformin oral agent alone, no insulin; (IV) T2DM receiving any insulin; and (V) T2DM not receiving medication. Outcome measures were overall survival, freedom from biochemical failure (BF), freedom from distant metastasis, cancer-specific survival, and toxicities. Kaplan-Meier analysis, log rank tests, Fine and Gray competing risk regression (to adjust for patient and lifestyle factors), Cox models, and subdistribution hazard ratios (sHRs) were used. RESULTS Of the 3217 patients, 1295 (40%) were low-risk, 1192 (37%) were intermediate-risk, and 652 (20%) were high risk. The group I to V distribution was 81%, 8%, 5%, 3%, and 4%. The median dose was 78 Gy, and the median follow-up time was 50 (range, 1-190) months. Group V had increased mortality (sHR, 2.1; 95% confidence interval [CI], 0.66-1.54), BF (sHR, 2.14; 0.88-1.83), and cause-specific mortality (sHR, 3.87; 95% CI, 1.31-11). Acute toxicities were higher in group IV versus group I (genitourinary: 38% vs. 26%; P = .01; gastrointestinal: 21% vs. 5%; P = 001). Late toxicities were higher in groups IV and V versus group I (12%-14% vs. 2%-6%; P < .01). CONCLUSION Men with T2DM not receiving medication and men with T2DM receiving insulin had worse outcomes and toxicities compared to other patients.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA.
| | - Talha Shaikh
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Karen Ruth
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA
| | - Pankaj Sharda
- Department of Endocrinology, Fox Chase Cancer Center, Philadelphia, PA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Mark L Sobczak
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Mark A Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Marc C Smaldone
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - David Y T Chen
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
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Avkshtol V, Dong Y, Hayes SB, Hallman MA, Price RA, Sobczak ML, Horwitz EM, Zaorsky NG. A comparison of robotic arm versus gantry linear accelerator stereotactic body radiation therapy for prostate cancer. Res Rep Urol 2016; 8:145-58. [PMID: 27574585 PMCID: PMC4993397 DOI: 10.2147/rru.s58262] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Prostate cancer is the most prevalent cancer diagnosed in men in the United States besides skin cancer. Stereotactic body radiation therapy (SBRT; 6–15 Gy per fraction, up to 45 minutes per fraction, delivered in five fractions or less, over the course of approximately 2 weeks) is emerging as a popular treatment option for prostate cancer. The American Society for Radiation Oncology now recognizes SBRT for select low- and intermediate-risk prostate cancer patients. SBRT grew from the notion that high doses of radiation typical of brachytherapy could be delivered noninvasively using modern external-beam radiation therapy planning and delivery methods. SBRT is most commonly delivered using either a traditional gantry-mounted linear accelerator or a robotic arm-mounted linear accelerator. In this systematic review article, we compare and contrast the current clinical evidence supporting a gantry vs robotic arm SBRT for prostate cancer. The data for SBRT show encouraging and comparable results in terms of freedom from biochemical failure (>90% for low and intermediate risk at 5–7 years) and acute and late toxicity (<6% grade 3–4 late toxicities). Other outcomes (eg, overall and cancer-specific mortality) cannot be compared, given the indolent course of low-risk prostate cancer. At this time, neither SBRT device is recommended over the other for all patients; however, gantry-based SBRT machines have the abilities of treating larger volumes with conventional fractionation, shorter treatment time per fraction (~15 minutes for gantry vs ~45 minutes for robotic arm), and the ability to achieve better plans among obese patients (since they are able to use energies >6 MV). Finally, SBRT (particularly on a gantry) may also be more cost-effective than conventionally fractionated external-beam radiation therapy. Randomized controlled trials of SBRT using both technologies are underway.
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Affiliation(s)
- Vladimir Avkshtol
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Yanqun Dong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark A Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Robert A Price
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark L Sobczak
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Zaorsky NG, Shaikh T, Murphy CT, Hallman MA, Hayes SB, Sobczak ML, Horwitz EM. Comparison of outcomes and toxicities among radiation therapy treatment options for prostate cancer. Cancer Treat Rev 2016; 48:50-60. [PMID: 27347670 DOI: 10.1016/j.ctrv.2016.06.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 06/07/2016] [Accepted: 06/08/2016] [Indexed: 01/13/2023]
Abstract
We review radiation therapy (RT) options available for prostate cancer, including external beam (EBRT; with conventional fractionation, hypofractionation, stereotactic body RT [SBRT]) and brachytherapy (BT), with an emphasis on the outcomes, toxicities, and contraindications for therapies. PICOS/PRISMA methods were used to identify published English-language comparative studies on PubMed (from 1980 to 2015) that included men treated on prospective studies with a primary endpoint of patient outcomes, with ⩾70 patients, and ⩾5year median follow up. Twenty-six studies met inclusion criteria; of these, 16 used EBRT, and 10 used BT. Long-term freedom from biochemical failure (FFBF) rates were roughly equivalent between conventional and hypofractionated RT with intensity modulation (evidence level 1B), with 10-year FFBF rates of 45-90%, 40-60%, and 20-50% (for low-, intermediate-, and high-risk groups, respectively). SBRT had promising rates of BF, with shorter follow-up (5-year FFBF of >90% for low-risk patients). Similarly, BT (5-year FFBF for low-, intermediate-, and high-risk patients have generally been >85%, 69-97%, 63-80%, respectively) and BT+EBRT were appropriate in select patients (evidence level 1B). Differences in overall survival, distant metastasis, and cancer specific mortality (5-year rates: 82-97%, 1-14%, 0-8%, respectively) have not been detected in randomized trials of dose escalation or in studies comparing RT modalities. Studies did not use patient-reported outcomes, through Grade 3-4 toxicities were rare (<5%) among all modalities. There was limited evidence available to compare proton therapy to other modalities. The treatment decision for a man is usually based on his risk group, ability to tolerate the procedure, convenience for the patient, and the anticipated impact on quality of life. To further personalize therapy, future trials should report (1) race; (2) medical comorbidities; (3) psychiatric comorbidities; (4) insurance status; (5) education status; (6) marital status; (7) income; (8) sexual orientation; and (9) facility-related characteristics.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Talha Shaikh
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Colin T Murphy
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark A Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark L Sobczak
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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