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Turkheimer LM, Yan J, Millard T, Ragoowansi H, Showalter SL. Overtreatment and Undertreatment of Early-Stage Breast Cancer in Older Women: Evaluating the POWER Trial. J Surg Res 2024; 302:585-592. [PMID: 39181025 DOI: 10.1016/j.jss.2024.07.027] [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: 03/05/2024] [Revised: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 08/27/2024]
Abstract
INTRODUCTION Radiation therapy (RT) omission is acceptable in older women with early-stage estrogen receptor + breast cancer treated with breast-conserving surgery (BCS) and adjuvant endocrine therapy (AET). However, RT rates in this population remain high, causing concern for overtreatment. Conversely, patients who omit RT and do not complete a course of AET are at risk of undertreatment. In the Pre-Operative Window of Endocrine Therapy to Inform Radiation Therapy Decisions (POWER) trial, participants receive 90 days of preoperative endocrine therapy to assess tolerance before deciding about RT. This study aimed to determine the rates of undertreatment and overtreatment institutionally and among POWER trial participants. METHODS Data were retrospectively collected from medical records of women aged ≥ 65 years diagnosed with invasive, estrogen receptor +/human epidermal growth factor receptor 2- breast cancer, ≤ 3 cm, who had BCS between 2012 and 2022. Patients were categorized as undertreated (BCS alone), overtreated (BCS + RT + AET), or appropriately treated (BCS + RT or BCS + AET). RESULTS The cohort included 478 patients, of whom 62 (12.97%) were undertreated, 202 (42.26%) were overtreated, and 214 (44.77%) were appropriately treated. Appropriately treated patients were more likely to be aged 70-79 years (P < 0.0001) and have high health literacy (P = 0.0003). Of the 37 patients (7.71%) in the POWER trial, more were appropriately treated than patients not in the POWER trial (81.1% versus 44.8%) (P < 0.0001). CONCLUSIONS Despite long-standing guideline changes, RT utilization remains high. This study highlights how a novel patient-centered approach to guide adjuvant therapy decisions may increase the number of appropriately treated patients.
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Affiliation(s)
- Lena M Turkheimer
- Department of Surgery, University Of Virginia, Charlottesville, Virginia
| | - Janet Yan
- School of Medicine, University Of Virginia, Charlottesville, Virginia
| | - Trish Millard
- Department of Medicine, University Of Virginia, Charlottesville, Virginia
| | - Henna Ragoowansi
- School of Medicine, University Of Virginia, Charlottesville, Virginia
| | - Shayna L Showalter
- Department of Surgery, University Of Virginia, Charlottesville, Virginia.
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Alfonzetti T, Moreau M, Yasmin-Karim S, Ngwa W, Avery S, Goia D. Phytoradiotherapy to enhance cancer treatment outcomes with cannabidiol, bitter melon juice, and plant hemoglobin. Front Oncol 2023; 12:1085686. [PMID: 36776362 PMCID: PMC9909600 DOI: 10.3389/fonc.2022.1085686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/02/2022] [Indexed: 01/28/2023] Open
Abstract
Despite technological advances in radiation therapy for cancer treatment, many patient populations still experience mediocre survival percentages, local control, and quality of life. Additionally, much of the world lacks access to expensive, modern treatment options. The need for innovative, cost-effective solutions that can improve patient treatment outcomes is essential. Phytomedicines have been shown to induce apoptotic tumor cell death, diminish tumor progression, reduce cancer incidence, alleviate harmful hypoxic conditions, and more. While an ample amount of research is available that characterizes many phytomedicines as having anti-cancer properties that increase tumor cell killing/control and mitigate the harmful side effects of radiation damage, little work has been done to investigate the synergistic effect of phytoradiotherapy: combining radiation treatment with phytomedicines. In this study, a protocol for testing the radiosensitizing effects of phytomedicines was validated and used to investigate the well-known plant based medicine cannabidiol (CBD) and the lesser-known medicinal fruit Bitter Melon. Additionally, based on its high concentration of plant hemoglobin which has been shown to abate hypoxia, the African-indigenous Justicia plant was tested in pancreatic adenocarcinoma mouse models. The studies reveal that these phytomedicines can effectively enhance tumor cell killing, minimize tumor growth, and prolong mice survival. There is certainly the need for additional research in this regard, however, phytoradiotherapy: the use of phytomedicines to enhance radiation therapy treatment outcomes, continues to show potential as a promising, innovative way to improve cancer care.
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Affiliation(s)
- Tyler Alfonzetti
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Michele Moreau
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Boston, MA, United States
| | - Sayeda Yasmin-Karim
- Department of Radiation Oncology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States,Department of Radiation Oncology, Dana Farber Cancer Institute and Harvard Medical School, Boston, MA, United States
| | - Wilfred Ngwa
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Boston, MA, United States
| | - Stephen Avery
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA, United States,*Correspondence: Stephen Avery,
| | - Denisa Goia
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Sinha S, Laskar SG, Wadasadawala T, Krishnatry R, Lievens Y, Agarwal JP. Adopting Health Economic Research in Radiation Oncology: A Perspective From Low- or Middle-Income Countries. JCO Glob Oncol 2022; 8:e2100374. [PMID: 35853193 PMCID: PMC9812487 DOI: 10.1200/go.21.00374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Establishing a new radiation therapy (RT) setup is resource-intensive as it involves substantial capital costs and the recruitment of a skilled workforce. It is essential to incorporate health economic analysis that estimates recurring and nonrecurring expenses on the basis of the national and local needs, infrastructure, and future projections. RT costing exercises can be especially relevant for low- or middle-income countries (LMICs) with more than 70% of the global cancer burden, with access to < 20% of the available resources. This review article summarizes the scope of RT costing exercises in LMICs, the hurdles in conducting them, and possible ways to circumvent them. The purpose of performing costing studies in RT lies in their utility to improve the efficiency of the investment while at the same time helping to address the issues of uniformity and equitable distribution of resources. This will help assess the net benefit from RT in terms of utility and outcome-linked parameters like Quality-Adjusted Life Years. There are numerous barriers to conducting economic evaluations in LMICs, including the lack of national costing values for equipment, data on manpower salary, cost for public and private setups, and indirect costs. The situation is further complicated because of the nonuniform pay structure, lack of an organizational framework, robust real-world data on outcomes, and nonavailability of country-specific reference utility values. Collaborative national efforts are required to collect all elements required to perform health technology assessments. Information from the national and hospital databases can be made available in the public domain to ease access and broader adoption of health economic end points in routine care. Although resource-intensive at the onset, costing studies and health economic assessments are essential for improving the coverage and quality of RT in LMICs.
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Affiliation(s)
- Shwetabh Sinha
- Department of Radiation Oncology, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India
| | - Sarbani Ghosh Laskar
- Department of Radiation Oncology, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India
| | - Tabassum Wadasadawala
- Department of Radiation Oncology, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India
| | - Rahul Krishnatry
- Department of Radiation Oncology, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Jai Prakash Agarwal
- Department of Radiation Oncology, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India,Jai Prakash Agarwal, MD, Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai 400012, India; e-mail:
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Alfonzetti T, Yasmin-Karim S, Ngwa W, Avery S. Phytoradiotherapy: An Integrative Approach to Cancer Treatment by Combining Radiotherapy With Phytomedicines. Front Oncol 2021; 10:624663. [PMID: 33628736 PMCID: PMC7898963 DOI: 10.3389/fonc.2020.624663] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/18/2020] [Indexed: 12/01/2022] Open
Abstract
Radiotherapy (RT) is an effective method of cancer treatment, but like any other method of cancer treatment, there are inherent limitations. While technological advances and a growing understanding of its biological effects have improved its results dramatically, the use of RT is still limited to certain patient populations and by normal tissue toxicities. The harmful side effects of treating patients with radiation can offset its therapy benefits, limiting its use in certain cases. Phyto, or plant-based, medicines offer a way to add to radiation treatment, while also protecting patients from its toxic side effects. Phytomedicines such as cannabinoids (CBD) and bitter melon extract have demonstrated therapeutic properties, including the ability to activate apoptotic death in cancer cells, diminish tumor progression, and generally decrease the incidence of several cancer types. In addition, herbal drugs have been shown to be powerful antioxidants with the ability to decrease toxicity of RT without the adverse side effects found in synthetic drugs. Furthermore, a number of phytomedicines have been shown to mitigate hypoxic conditions within the tumor microenvironment, creating a more radiosensitive disease and preventing tumorigenesis. The purpose of this article is to examine the merits and demerits of employing phytomedicines during RT. Results from studies that have tested the effects of combining radiotherapy with supplemental herbal treatment are discussed along with perspectives on where additional research is needed to advance "Phytoradiotherapy". Overall, experimental evidence points to the fact that phytomedicines have significant potential to enhance RT, with need for cross-disciplinary collaborations to establish optimal dosing combinations with evidence-base for clinical translation.
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Affiliation(s)
- Tyler Alfonzetti
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sayeda Yasmin-Karim
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Wilfred Ngwa
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Stephen Avery
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Is SABR Cost-Effective in Oligometastatic Cancer? An Economic Analysis of the SABR-COMET Randomized Trial. Int J Radiat Oncol Biol Phys 2020; 109:1176-1184. [PMID: 33309977 DOI: 10.1016/j.ijrobp.2020.12.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/25/2020] [Accepted: 12/01/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The phase 2 randomized study SABR-COMET demonstrated that in patients with controlled primary tumors and 1 to 5 oligometastatic lesions, SABR was associated with improved progression-free survival (PFS) compared with standard of care (SoC), but with higher costs and treatment-related toxicities. The aim of this study was to assess the cost-effectiveness of SABR versus SoC in this setting. METHODS AND MATERIALS A Markov model was constructed to perform a cost-utility analysis from the Canadian health care system perspective. Utility values and transition probabilities were derived from individual-level data from the SABR-COMET trial. One-way, 2-way, and probabilistic sensitivity analyses were performed. Costs were expressed in 2018 CAD. A separate analysis based on US payer's perspective was performed. An incremental cost-effectiveness ratio (ICER) at a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) was used. RESULTS In the base case scenario, SABR was cost-effective at an ICER of $37,157 per QALY gained. This finding was most sensitive to the number of metastatic lesions treated with SABR (ICER: $28,066 per QALY for 2, increasing to $64,429 per QALY for 5), difference in chemotherapy use (ICER: $27,173-$53,738 per QALY), and PFS hazard ratio (HR) between strategies (ICER: $31,548-$53,273 per QALY). Probabilistic sensitivity analysis revealed that SABR was cost-effective in 97% of all iterations. Two-way sensitivity analysis demonstrated a nonlinear relationship between the number of lesions and the PFS HR. To maintain cost-effectiveness for each additional metastasis, the HR must decrease by approximately 0.047. The US cost analysis yielded similar results, with an ICER of $54,564 (2018 USD per QALY) for SABR. CONCLUSIONS SABR is cost-effective for patients with 1 to 5 oligometastatic lesions compared with SoC.
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Ning MS, Venkatesan AM, Stafford RJ, Bui TP, Carlson R, Bailard NS, Vedam S, Davis R, Olivieri ND, Guzman AB, Incalcaterra JR, McKelvey FA, Thaker NG, Rauch GM, Tang C, Frank SJ, Joyner MM, Lin LL, Jhingran A, Eifel PJ, Klopp AH. Developing an intraoperative 3T MRI-guided brachytherapy program within a diagnostic imaging suite: Methods, process workflow, and value-based analysis. Brachytherapy 2020; 19:427-437. [DOI: 10.1016/j.brachy.2019.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/11/2019] [Accepted: 09/21/2019] [Indexed: 12/22/2022]
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Comparative cost of transoral robotic surgery and radiotherapy (IMRT) in early stage tonsil cancer. Am J Otolaryngol 2020; 41:102409. [PMID: 32057489 DOI: 10.1016/j.amjoto.2020.102409] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE To compare treatment costs and cost-effectiveness for transoral robotic surgery (TORS) and definitive intensity-modulated radiotherapy (IMRT) in managing early stage tonsil cancer. MATERIALS AND METHODS Direct treatment costs for surgery and IMRT were calculated from SEER-Medicare data for a cohort with clinically early stage (cT1/2N0) p16+ tonsillar squamous cell carcinoma from Kaiser Permanente Southern California Health Plan between 2012 and 2017. A Markov decision tree model with a 5-year time horizon was then applied to the cohort which incorporated costs associated with treatment, surveillance, and recurrence. RESULTS IMRT cost up to $19,000 more (35%) than TORS in direct treatment costs. When input into the Markov model, TORS dominated IMRT with lower cost and better effectiveness over a range of values. CONCLUSION TORS is a more cost-effective treatment method than IMRT in early stage (cT1/2N0) tonsil cancer.
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Tchelebi LT, Lehrer EJ, Trifiletti DM, Sharma NK, Gusani NJ, Crane CH, Zaorsky NG. Conventionally fractionated radiation therapy versus stereotactic body radiation therapy for locally advanced pancreatic cancer (CRiSP): An international systematic review and meta-analysis. Cancer 2020; 126:2120-2131. [PMID: 32125712 DOI: 10.1002/cncr.32756] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 12/29/2019] [Accepted: 12/30/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The goal of this study was to characterize the efficacy and safety of stereotactic body radiation therapy (SBRT) versus conventionally fractionated radiation therapy with concurrent chemotherapy (CFRT) for the definitive treatment of locally advanced pancreatic cancer. The primary outcome measure was efficacy, defined by 2-year overall survival (OS). Secondary outcomes were incidence of any grade 3/4 toxicity and 1-year OS. METHODS A PICOS/PRISMA/MOOSE selection protocol was used to identify eligible studies. Inclusion criteria were: 1) patients diagnosed with locally advanced N0-1 M0 pancreatic cancer; 2) CFRT 1.8 to 2.0 Gy/fraction with chemotherapy per protocol or SBRT ≥5 Gy/fraction in ≤5 fractions; 3) either no control group or another definitive chemotherapy or radiation therapy arm; 4) at least 1 of the outcome measures reported; and 5) single or multi-arm phase 2/3 prospective study for CFRT and/or phase 1/2 or retrospective study for SBRT. Neoadjuvant and/or adjuvant chemotherapy was prescribed per protocol specifications. Weighted random effects meta-analyses were conducted using the DerSimonian and Laird method to characterize summary effect sizes for each outcome. RESULTS A total of 470 studies were initially screened; of these, 9 studies assessed SBRT and 11 studies assessed CFRT. For SBRT, the median dose was 30 Gy, and the most common regimen was 30 Gy/5 fractions. For CFRT, doses ranged from 45 to 54 Gy in 1.8- to 2.0-Gy fractions, with the majority of studies delivering 50.4 Gy in 28 fractions with concurrent gemcitabine. The random effects estimate for 2-year OS was 26.9% (95% CI, 20.6%-33.6%) for SBRT versus 13.7% (95% CI, 8.9%-19.3%) for CFRT and was statistically significant in favor of SBRT. The random effects estimate for 1-year OS was 53.7% (95% CI, 39.3%-67.9%) for SBRT versus 49.3% (95% CI, 39.3%-59.4%) for CFRT, and was not statistically significant. The random effects estimate for acute grade 3/4 toxicity was 5.6% (95% CI, 0.0%-20.0%) for SBRT versus 37.7% (95% CI, 24.0%-52.5%) for CFRT and was statistically significant in favor of SBRT. The random effects estimate for late grade 3/4 toxicity was 9.0% for SBRT (95% CI, 3.3%-17.1%) versus 10.1% (95% CI, 1.8%-23.8%) for CFRT, which was not statistically significant. CONCLUSION These results suggest that SBRT for LAPC may result in a modest improvement in 2-year OS with decreased rates of acute grade 3/4 toxicity and no change in 1-year-OS or late toxicity. Further study into the use of stereotactic body radiation therapy for these patients is needed.
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Affiliation(s)
- Leila T Tchelebi
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Navesh K Sharma
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Niraj J Gusani
- Department of Surgery, Penn State College of Medicine, Hershey, Pennsylvania.,Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - 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
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Mittmann N, Liu N, Cheng SY, Seung SJ, Saxena FE, Look Hong NJ, Earle CC, Cheung MC, Leighl NB, Coburn NG, DeAngelis C, Evans WK. Health system costs for cancer medications and radiation treatment in Ontario for the 4 most common cancers: a retrospective cohort study. CMAJ Open 2020; 8:E191-E198. [PMID: 32184283 PMCID: PMC7082106 DOI: 10.9778/cmajo.20190114] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Previous costing and resource estimates for cancer have not been complete owing to lack of comprehensive data on cancer-related medication and radiation treatment. Our objective was to calculate the mean overall costs per patient of cancer-related medications and radiation, as well as by disease subtype and stage, in the first year after diagnosis for the 4 most prevalent cancers in Ontario. METHODS We conducted a retrospective cohort study using provincial health administrative databases to identify population health system resources and costs for all patients diagnosed with breast, colorectal, lung or prostate cancer between Jan. 1, 2010, and Dec. 31, 2015 in Ontario. The primary outcome measure was the overall average cost per patient in the 365 days after diagnosis for cancer-related medications and radiation treatment, calculated with the use of 2 novel costing algorithms. We determined the cost by disease, disease subtype and stage as secondary outcomes. RESULTS There were 168 316 Ontarians diagnosed with cancer during the study period, 50 141 with breast cancer, 38 108 with colorectal cancer, 34 809 with lung cancer and 45 258 with prostate cancer. The mean per-patient cost for cancer-related medications was $8167 (95% confidence interval [CI] $8023-$8311), $6568 (95% CI $6446-$6691), $2900 (95% CI $2816-$2984) and $1211 (95% CI $1175-$1247) for breast, colorectal, lung and prostate cancer, respectively. The corresponding mean radiation treatment costs were $18 529 (95% CI $18 415-$18 643), $15 177 (95% CI $14 899-$15 456), $10 818 (95% CI $10 669-$10 966) and $16 887 (95% CI $16 648-$17 125). In general, stage III and IV cancers were the most expensive stages for both medications and radiation across all 4 disease sites. INTERPRETATION Our work updates previous costing estimates to help understand costs and resources critical to health care system planning in a single-payer system. More refined costing estimates are useful as inputs to allow for more robust health economic modelling and health care system planning.
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Affiliation(s)
- Nicole Mittmann
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont.
| | - Ning Liu
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont
| | - Stephanie Y Cheng
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont
| | - Soo Jin Seung
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont
| | - Farah E Saxena
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont
| | - Nicole J Look Hong
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont
| | - Craig C Earle
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont
| | - Matthew C Cheung
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont
| | - Natasha B Leighl
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont
| | - Natalie G Coburn
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont
| | - Carlo DeAngelis
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont
| | - William K Evans
- Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont
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Critical review of multidisciplinary non-surgical local interventional ablation techniques in primary or secondary liver malignancies. J Contemp Brachytherapy 2019; 11:589-600. [PMID: 31969919 PMCID: PMC6964346 DOI: 10.5114/jcb.2019.90466] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/15/2019] [Indexed: 12/21/2022] Open
Abstract
Local non-surgical interventional percutaneous ablation represents nowadays an important part of the potential treatment strategies. Although surgical ablation represents the gold standard, in the past decade there was an expansion in the use of non-surgical ablative techniques: radiofrequency, microwave, laser, cryoablation, irreversible electroporation, and interventional radiotherapy (brachytherapy) in primary as well as secondary liver cancers. With the growing experience in the field, there was implemented a new pillar for cancer treatment, together with surgery, chemotherapy as well as radiotherapy, so-called interventional oncology (IO). To date, there are no published papers regarding a comparative interdisciplinary evaluation of all these non-surgical interventional local ablation therapies. Our paper offers a critical interdisciplinary overview of the treatments in both primary and secondary liver tumors, including from a cost-effective point of view. Furthermore, the present status of education in IO and a comparison of actual economic aspects of the treatments are also provided.
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Mittmann N, Cheng SY, Liu N, Seung SJ, Saxena FE, DeAngelis C, Hong NJL, Earle CC, Cheung MC, Leighl N, Coburn N, Evans WK. The generation of two specific cancer costing algorithms using Ontario administrative databases. ACTA ACUST UNITED AC 2019; 26:e682-e692. [PMID: 31708661 DOI: 10.3747/co.26.5279] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cancer treatment and management have become increasingly economically burdensome. Consequently, to help with planning health service delivery, it is vital to understand the associated costs. Administrative databases can be used to help understand and generate real-world system-level costs. Using databases to generate costs can take one of two approaches: top-down or bottom-up. Top-down approaches disaggregate the total health care spending from a global health care budget by sector and provider. A bottom-up approach begins with individual-level health care use and its costs, which are then aggregated.
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Affiliation(s)
- N Mittmann
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto.,Cancer Care Ontario, Toronto
| | | | | | - S J Seung
- Health Outcomes and PharmacoEconomic (hope) Research Centre, Toronto
| | | | - C DeAngelis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto
| | - N J Look Hong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto
| | - C C Earle
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto.,ices, Toronto.,Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto
| | - M C Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto
| | - N Leighl
- University Health Network, Toronto
| | - N Coburn
- ices, Toronto.,Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto
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12
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Ning MS, Klopp AH, Jhingran A, Lin LL, Eifel PJ, Vedam S, Lawyer AA, Olivieri ND, Guzman AB, Incalcaterra JR, Mesko SM, Pezzi TA, Boyce-Fappiano DR, Shaitelman SF, Frank SJ, Thaker NG. Quantifying institutional resource utilization of adjuvant brachytherapy and intensity-modulated radiation therapy for endometrial cancer via time-driven activity-based costing. Brachytherapy 2019; 18:445-452. [DOI: 10.1016/j.brachy.2019.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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13
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Dohopolski MJ, Glaser SM, Vargo JA, Balasubramani GK, Beriwal S. Stereotactic body radiotherapy for locally-advanced unresectable pancreatic cancer-patterns of care and overall survival. J Gastrointest Oncol 2017; 8:766-777. [PMID: 29184680 PMCID: PMC5674248 DOI: 10.21037/jgo.2017.08.04] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 06/19/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Unresectable pancreatic cancer remains a challenging disease to treat. Stereotactic body radiotherapy (SBRT) allows for a higher biologically equivalent dose in an abbreviated course more convenient for patients and the integration of systemic therapy. We sought to investigate utilization trends and survival outcomes for patients treated with pancreatic SBRT versus conventionally fractionated radiotherapy (CFRT). METHODS We engaged the National Cancer Database (NCDB) from 1998-2012 and identified locally-advanced unresectable patients with histologically confirmed, non-metastatic, pancreatic adenocarcinoma who received radiotherapy. Patients who received CFRT (1.5-4.0 Gy per fraction to a dose of ≥45 Gy, n=11,879) were compared to those who received SBRT (6-15 Gy per fraction to a dose of ≥20 Gy, n=474). RESULTS Median follow-up was 11.0 months (18.4 months for survivors). SBRT utilization increased from 0.2% to 7.4% from 1998 to 2012 (P<0.05). On multivariable analysis, factors predictive for preferential utilization of SBRT over CFRT were later year of diagnosis, age ≥75 years, increased facility volume, and no chemotherapy in the initial treatment plan. Unadjusted median survival was 11.2 months for CFRT vs. 12.6 months for SBRT (P=0.002). Results were consistent in the propensity matched model. Variables predictive for improved survival on multivariable analysis were diagnosis after 2010, younger age, lower comorbidity score, tumor size <3 cm, nodal stage zero, and receipt of chemotherapy (P<0.05). CONCLUSIONS SBRT utilization has increased significantly and is associated with a small absolute improvement in overall survival (OS) compared to CFRT. The decreased treatment time, without apparent compromise in survival, makes SBRT an attractive option for patients with unresectable pancreatic cancer warranting further research.
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Affiliation(s)
- Michael J. Dohopolski
- Department of Radiation Oncology, University Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Scott M. Glaser
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - John A. Vargo
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | | | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
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14
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Westhoff PG, de Graeff A, Monninkhof EM, de Pree I, van Vulpen M, Leer JWH, Marijnen CAM, van der Linden YM. Effectiveness and toxicity of conventional radiotherapy treatment for painful spinal metastases: a detailed course of side effects after opposing fields versus a single posterior field technique. ACTA ACUST UNITED AC 2017; 7:17-26. [PMID: 29576859 PMCID: PMC5856865 DOI: 10.1007/s13566-017-0328-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 09/08/2017] [Indexed: 12/25/2022]
Abstract
Background Conventional radiotherapy for painful spinal metastases can be delivered with a single posterior-anterior (PA) or two opposed anterior-posterior (APPA) fields. We studied the effectiveness and toxicity of both techniques and studied whether treatment technique was predictive for abdominal and skin toxicity. Patients and methods Within the Dutch Bone Metastasis Study, 343 patients received 8 Gray in a single fraction or 24 Gray in six fractions for painful spinal metastases. Treatment technique was not randomized. At baseline and weekly during follow-up, patients reported pain and other physical complaints. Any complaint increasing within 4 weeks after treatment was noted as a side effect. Pain response was calculated according to international standards, taking into account changes in pain score and medication. Repeated measurement analyses and multivariate logistic analyses were performed. Results Patients were mainly treated on the thoracic (34%) and lumbar (53%) spine and 73% received a PA field. Pain response was similar between both techniques (74%). In patients treated at the thoraco-lumbar and lumbar spine, with multiple fractions, significantly more abdominal complaints were noticed. In multivariate analysis, radiotherapy technique did not predict for side effects. Conclusion Conventional radiotherapy of painful spinal metastases provides limited toxicity. Radiotherapy technique is not an independent predictor of abdominal and skin toxicity of irradiation.
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Affiliation(s)
- Paulien G Westhoff
- 1Department of Radiation Oncology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands.,2Department of Radiation Oncology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Alexander de Graeff
- 3Department of Medical Oncology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Evelyn M Monninkhof
- 4Julius center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Ilse de Pree
- 5Department of Radiation Oncology, Erasmus Medical Center, PO Box 5201, 3008 AE Rotterdam, the Netherlands
| | - Marco van Vulpen
- 1Department of Radiation Oncology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Jan Willem H Leer
- 2Department of Radiation Oncology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Corrie A M Marijnen
- 6Department of Radiation Oncology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - Yvette M van der Linden
- 6Department of Radiation Oncology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands
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15
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Comparison of the efficacy between intensity-modulated radiotherapy and two-dimensional conventional radiotherapy in stage II nasopharyngeal carcinoma. Oncotarget 2017; 8:78096-78104. [PMID: 29100451 PMCID: PMC5652840 DOI: 10.18632/oncotarget.17481] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 04/12/2017] [Indexed: 12/16/2022] Open
Abstract
We compared treatment outcomes in patients with stage II nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy (IMRT) or two-dimensional conventional radiotherapy (2D-CRT). Stage II (2010 UICC/AJCC staging system) NPC patients treated with IMRT (n = 178) or 2D-CRT (n = 73) between January 2007 and December 2014 were retrospectively analyzed. Patients were matched using the propensity score-matching method. The primary endpoint was overall survival (OS). Secondary endpoints were local relapse-free survival (LRFS), regional relapse-free survival (RRFS), distant metastasis-free survival (DMFS), and disease-free survival (DFS). Acute and late toxicity reactions to IMRT and 2D-CRT were also compared. In an unmatched cohort of 251 patients, no significant survival differences were found between those receiving IMRT and those receiving 2D-CRT (5-year OS, 95.67% vs 94.44%, P = 0.0556; LRFS, 97.34% vs 98.59%, P = 0.6656; RRFS, 99.26% vs 100%, P = 0.6785; DMFS, 96.5% vs 98.63%, P = 0.7910; DFS, 92.2% vs 97.24%, P = 0.8719). In the propensity-matched cohort of 146 patients, 5-year OS (97.06% vs 94.44%, P = 0.1325), LRFS (96.75% vs 98.59%, P = 0.8869), RRFS (100% vs 100%, P = 1.0000), DMFS (98.63% vs 98.63%, P = 0.4225), and DFS (95.37% vs 97.24%, P = 0.5634) were similar between patients treated with IMRT or 2D-CRT. However, IMRT correlated with fewer acute and late toxicity reactions. Thus although IMRT provides no survival advantage, it has a lower incidence of toxicity than 2D-CRT in stage II NPC patients.
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