Common Sense (Radiation) Oncology: Redefining targets in radiotherapy

In 2023, the Common Sense Oncology (CSO) movement was launched with the goal of recalibrating cancer care to focus on outcomes that matter to patients. We extend the three CSO pillars - evidence generation, interpretation and communication - to radiation oncology and advocate for better evidence demonstrating the value of our modality.

Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

Real-World Evidence on the Use of Endocrine Therapy for Ductal Carcinoma In Situ in Patients Treated With Breast-Conserving Surgery Followed by Postoperative Radiation Therapy: A Brazilian Retrospective Cohort Study

INTRODUCTION/BACKGROUND

This study aims to evaluate the reproducibility of findings from randomized controlled trials regarding adjuvant hormone therapy (HT) for breast ductal carcinoma in situ (DCIS) in a real-life scenario.

MATERIALS/METHODS

This retrospective cohort study used Fundação Oncocentro de São Paulo database. It included DCIS patients DCIS who received breast-conserving surgery and postoperative radiation therapy. The endpoints were local control (LC), breast cancer-specific survival (BCSS), and overall survival (OS).

RESULTS

We analyzed 2192 patients treated between 2000 and 2020. The median FU was 48.99 months. Most patients (53.33%; n = 1169) received adjuvant HT. Patients not receiving adjuvant HT tend to be older (P = .021) and have a lower educational level (P < .001). At the end of FU, 1.5% of patients had local recurrence, and there was no significant difference between groups (P = .19). The 10-year OS and BCSS were 89.4% and 97.5% for adjuvant HT versus 91.5% and 98.5% for no adjuvant HT, respectively, and there were no significant differences between groups. The 10-year OS was 93.25% for medium/high education level versus 87.31% for low (HR for death 0.51; 95% CI, 0.32-0.83; P = .007).

CONCLUSIONS

The benefits of adjuvant HT for DCIS were not reproduced in a Brazilian cohort. Education significantly impacted survival and HT usage, reflecting the influence of socioeconomic factors. These findings can allow for more precise interventions.

The Choosing Wisely Oncology Canada Cancer List: An Update

BACKGROUND

Choosing Wisely (CW) Canada is a national campaign to identify unnecessary or harmful services that are frequently used in Canada. The original CW Oncology Canada Cancer list was developed in 2014. A CW Oncology Canada working group was established to review new evidence and guidelines and to update the current CW Oncology Canada Cancer List.

METHODS

Between January and March 2022, we conducted a survey of members of the Canadian Association of Medical Oncology (CAMO), Canadian Association of Radiation Oncology (CARO) and the Canadian Society of Surgical Oncology (CSSO). We took the feedback from the survey, including potential new recommendations as well as those that were thought to be no longer relevant and up to date, and conducted a literature review with the assistance of the Canadian Agency for Drugs and Technology in Health (CADTH). The final updated list of recommendations was made by the CW Oncology Canada working group based on a consensus process.

RESULTS

We reviewed two potential recommendations to add and two potential recommendations to remove from the existing CW Oncology Canada Cancer List. The recommendation "Do not prescribe whole brain radiation over stereotactic radiosurgery for patient with limited brain metastases (≤4 lesions)" was supported by several evidence-based guidelines with the strength of recommendations ranging from strong to moderate and the quality of evidence ranging from level 1 to level 3. After reviewing the evidence, the working group felt that the other potential recommendation to add and the two potential recommendations to remove did not have sufficient strength and quality of evidence at this time to be added or removed from the list.

CONCLUSION

The updated Choosing Wisely Oncology Canada Cancer List consists of 11 items that oncologists should question in the treatment of patients with cancer. This list can be used to design specific interventions to reduce low value care.

Recommended first-line management of asymptomatic brain metastases from EGFR mutant and ALK positive non-small cell lung cancer varies significantly according to specialty: an international survey of clinical practice

Background

The role for radiotherapy or surgery in the upfront management of brain metastases (BrM) in epidermal growth factor receptor mutant (EGFRm) or anaplastic lymphoma kinase translocation positive (ALK+) non-small cell lung cancer (NSCLC) is uncertain because of a lack of prospective evidence supporting tyrosine kinase inhibitor (TKI) monotherapy. Further understanding of practice heterogeneity is necessary to guide collaborative efforts in establishing guideline recommendations.

Methods

We conducted an international survey among medical (MO), clinical (CO), and radiation oncologists (RO), as well as neurosurgeons (NS), of treatment recommendations for asymptomatic BrM (in non-eloquent regions) EGFRm or ALK+ NSCLC patients according to specific clinical scenarios. We grouped and compared treatment recommendations according to specialty. Responses were summarized using counts and percentages and analyzed using the Fisher exact test.

Results

A total of 449 surveys were included in the final analysis: 48 CO, 85 MO, 60 NS, and 256 RO. MO and CO were significantly more likely than RO and NS to recommend first-line TKI monotherapy, regardless of the number and/or size of asymptomatic BrM (in non-eloquent regions). Radiotherapy in addition to TKI as first-line management was preferred by all specialties for patients with ≥4 BrM. NS recommended surgical resection more often than other specialties for BrM measuring >2 cm.

Conclusions

Recommendations for the management of BrM from EGFRm or ALK+ NSCLC vary significantly according to oncology sub-specialties. Development of multidisciplinary guidelines and further research on establishing optimal treatment strategies is warranted.

Survival outcomes and predicting intracranial metastasis in stage III non-small cell lung cancer treated with definitive chemoradiation: Real-world data from a tertiary cancer center

PURPOSE/OBJECTIVE

Around 30% of patients with non-small cell lung cancers (NSCLC) are diagnosed with stage III disease at presentation, of which about 50% are treated with definitive chemoradiation (CRT). Around 65-80% of patients will eventually develop intracranial metastases (IM), though associated risk factors are not clearly described. We report survival outcomes and risk factors for development of IM in a cohort of patients with stage III NSCLC treated with CRT at a tertiary cancer center.

MATERIALS/METHODS

We identified 195 patients with stage III NSCLC treated with CRT from January 2010 to May 2021. Multivariable logistic regression was used to generate odds ratios for covariates associated with development of IM. Kaplan-Meier analysis with the Log Rank test was used for unadjusted time-to-event analyses. P-value for statistical significance was set at < 0.05 with a two-sided test.

RESULTS

Out of 195 patients, 108 (55.4%) had stage IIIA disease and 103 (52.8%) had adenocarcinoma histology. The median age and follow-up (in months) was 67 (IQR 60-74) and 21 (IQR 12-43), respectively. The dose of radiation was 60 Gy in 30 fractions for148 patients (75.9%). Of the 77 patients who received treatment since immunotherapy was available and standard at our cancer center, 45 (58.4%) received at least one cycle. During follow-up, 84 patients (43.1%) developed any metastasis, and 33 (16.9%) developed IM (either alone or with extracranial metastasis). 150 patients (76.9%) experienced a treatment delay (interval between diagnosis and treatment > 4 weeks). Factors associated with developing any metastasis included higher overall stage at diagnosis (p = 0.013) and higher prescribed dose (p = 0.022). Factors associated with developing IM included higher ratio of involved over sampled lymph nodes (p = 0.001) and receipt of pre-CRT systemic or radiotherapy for any reason (p = 0.034). On multivariate logistical regression, treatment delay (OR 3.9, p = 0.036) and overall stage at diagnosis (IIIA vs. IIIB/IIIC) (OR 2.8, p = 0.02) predicted development of IM. These findings were sustained on sensitivity analysis using different delay intervals. Median OS was not reached for the overall cohort, and was 43.1 months for patients with IM and 40.3 months in those with extracranial-only metastasis (p = 0.968). In patients with any metastasis, median OS was longer (p = 0.003) for those who experienced a treatment delay (48.4 months) compared to those that did not (12.2 months), likely due to expedited diagnosis and treatment in patients with a higher symptom burden secondary to more advanced disease.

CONCLUSIONS

In patients with stage III NSCLC treated with definitive CRT, the risk of IM appears to increase with overall stage at diagnosis and, importantly, may be associated with experiencing a treatment delay (> 4 weeks). Metastatic disease of any kind remains the primary life-limiting prognostic factor in these patients with advanced lung cancer. In patients with metastatic disease, treatment delay was associated with better survival. Patients who experience a treatment delay and those initially diagnosed at a more advanced overall stage may warrant more frequent surveillance for early diagnosis and treatment of IM. Healthcare system stakeholders should strive to mitigate treatment delay in patients with locally NSCLC to reduce the risk of IM. Further research is needed to better understand factors associated with survival, treatment delay, and the development of IM after CRT in the immunotherapy era.

Are the Choosing Wisely Canada Cancer recommendations relevant and up to date with the current evidence?

INTRODUCTION

The Choosing Wisely (CW) Canada campaign was launched in 2012 to identify low-value, unnecessary and/or harmful services that are frequently used. The CW Canada Cancer list was developed in 2014 by a task force convened by the Canadian Partnership Against Cancer. The list outlines ten harmful or low-value practices that oncologists should avoid. We conducted a study of oncologists to understand the familiarity with the current recommendations and whether these continue to be relevant and up to date.

METHODS

An electronic survey was developed by the members of the CW Oncology Working Group and distributed to practicing oncologists. The survey consisted of questions on 1) the familiarity of the existing CW Canada Cancer list 2) the relevance of the current list to current evidence and 3) any recommendation(s) that could be added or removed from the existing list. Descriptive statistics were used to analyze responses and narrative analysis was used to identify themes in open-ended questions.

RESULTS

Between January 14 and May 3, 2022, 151 survey responses were received (overall response rate of 20 %) from 68 medical oncologists (45 % of study cohort, response rate 32 %), 54 radiation oncologists (36 % of study cohort, response rate 14 %) and 29 surgical oncologists (19 % of study cohort, response rate 18 %). Seventy-nine percent (120/151) of respondents were familiar with the current list and 65 % (78/119) said they implemented the recommendations "always" or "most of the time". Eight recommendations had > 80 % agreement that they were relevant and up to date with current evidence. There was interest in adding a new recommendation to avoid whole brain radiation and consider stereotactic radiosurgery (SRS) in patients with ≤ 4 brain metastases.

CONCLUSIONS

There is excellent familiarity with the CW Canada Cancer list amongst the survey respondents and most recommendations continue to be relevant and up to date with current evidence. There is an opportunity to educate physicians about the intent of the campaign and to add a new recommendation on the use of SRS for patients with a limited number of brain metastases. There is also an opportunity to identify barriers at the patient, provider and institution level that are hindering adoption of the CW Canada Cancer list POLICY SUMMARY: This survey will impact implementation and publication of an updated CW Canada Cancer list.

Radiotherapy prioritization in 143 national cancer control plans: Correlation with radiotherapy machine availability, geography and income level

BACKGROUND

In 2015, the Global Task Force on Radiotherapy for Cancer Control (GTFRCC) called for 80% of National Cancer Control Plans (NCCP) to include radiotherapy by 2020. As part of the ongoing ESTRO Global Impact of Radiotherapy in Oncology (GIRO) project, we assessed whether inclusion of radiotherapy in NCCPs correlates with radiotherapy machine availability, national income, and geographic region.

METHODS

A previously validated checklist was used to determine whether radiotherapy was included in each country's NCCP. We applied the CCORE optimal radiotherapy utilisation model to the GLOBOCAN 2020 data to estimate the demand for radiotherapy and compared this to the International Atomic Energy Agency (IAEA) Directory of Radiotherapy Centres (DIRAC) supply data, stratifying by income level and world region. World regions were defined according to the IAEA.

FINDINGS

Complete data (including GLOBOCAN 2020, DIRAC and NCCP) was available for 143 countries. Over half (55%, n = 79) included a radiotherapy-specific checklist item within the plan. Countries which included radiotherapy services planning in their NCCP had a higher median number of machines (1.68 vs 0.75 machines/1000 patients needing radiotherapy, p < 0.001). There was significant regional and income-level heterogeneity in the inclusion of radiotherapy-related items in NCCPs. Low-income and Asia-Pacific countries were least likely to include radiation oncology services planning in their NCCP (p = 0.06 and p = 0.003, respectively). Few countries in the Asia-Pacific (18.6%) had a plan to develop or maintain radiation services, compared to 57% of countries in Europe.

INTERPRETATION

Only 55% of current NCCPs included any information regarding radiotherapy, below the GTFRCC's target of 80%. Prioritisation of radiotherapy in NCCPs was correlated with radiotherapy machine availability. There was regional and income-level heterogeneity regarding the inclusion of specific radiotherapy checklist items in the NCCPs. Ongoing efforts are needed to promote the inclusion of radiotherapy in future iterations of NCCPs in order to improve global access to radiation treatment.

FUNDING

No direct funding was used in this research.

The need for artificial intelligence curriculum in medical education: A Canadian cross-sectional study of future oncology trainees

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Background: Emerging artificial intelligence (AI) technologies have diverse applications in medicine, with early evidence suggesting that AI tools can accurately perform key tasks in oncology. As AI tools advance towards clinical implementation, skills in how to use and interpret AI in a healthcare setting could become integral for physicians. This study seeks to assess exposure to AI in medical education among trainees interested in pursuing a career in oncology, and the need for AI education in medicine. Methods: A 32 question survey for Canadian undergraduate medical students was distributed to students at all 17 Canadian medical schools. The survey assessed the currently available and perceived need for learning opportunities about AI and barriers to educating about AI in medicine. Interviews were conducted with participants to provide narrative context to survey responses. Likert scale (LS) survey questions were scored from 1 (disagree) to 5 (agree), and analyzed using a two-sided one sample t-test vs a neutral value. Interview transcripts were analyzed using qualitative thematic analysis. Results are described as mean LS score ± standard deviation. Results: We received 486 responses from 17 of 17 medical schools. Of these respondents, 98 (20.2%) are willing to pursue a residency in an oncology-related field (pathology, radiology, general surgery, internal medicine, radiation oncology). Respondents agreed that AI applications in medicine would become common in the future (3.80±0.38) and would improve medicine (3.71±0.54). Further, respondents agreed that they would need to use and understand AI during their medical careers (3.76±0.572; 3.43±0.773), and that AI should be formally taught in medical education (3.43±0.756). In contrast, a significant number of participants indicated that they did not have any formal educational opportunities about AI (1.76±0.785) and that AI-related learning opportunities were inadequate (2.12±0.802). Interviews with 18 students were conducted. Emerging themes from the interviews were a lack of formal education opportunities and logistical challenges in adding AI to curriculum. Conclusions: A lack of educational opportunities about AI in medicine were identified across Canadian medical students. Given that medical students overwhelmingly believe that AI is important to the future of medicine, and AI tools are currently progressing towards clinical implementation, AI should be considered for inclusion in formal medical curriculum.

Canadian oncology residents’ knowledge of and attitudes towards artificial intelligence and machine learning

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Background: The use of artificial intelligence (AI) and machine learning is becoming more common and is expected to expand further in order to meet the needs of our ever-evolving healthcare system. In oncology, AI and machine learning are already being explored in various applications. Despite AI’s importance, there is sparse formal teaching on AI incorporated into medical schools’ curricula and residency training programs. In this study, we examined the perceptions and knowledge of Canadian oncology residents and fellows with respect to AI technologies. Methods: An electronic, anonymous, questionnaire-based survey was distributed to residents and fellows in medical and radiation oncology programs across Canada. Survey questions spanned areas of demographics, familiarity with AI, personal attitudes towards AI, and perspectives regarding AI use in different specialties. Approval was obtained from the Queen’s Research Ethics Board prior to conducting this study. Mixed-methods statistical analysis is ongoing. Qualitative data will be analyzed using thematic analysis. Univariable and multivariable regressions will be conducted to identify any correlation between perception or knowledge of AI and demographic factors. Results: Fifty-seven participants responded in total. Most residents (67%) agreed or strongly agreed that it was important they learn about AI. Seventy percent indicated that, if given the chance, they would like to learn more about AI, yet the majority of participants (88%) indicated they had not received formalized teaching. Disciplines that were felt to be most associated with AI were radiology (98%), radiation oncology (84%), and pathology (58%). With respect to the field of radiation oncology, 98% of respondents felt that AI had the potential to replace some, most, or all medical activities. A perceived barrier to understanding AI was a lack of knowledge of mathematics and programming (63%). Respondents indicated that their preferred formats for learning about AI would be workshops (78%), lectures (60%), and collaborative activities with other departments (46%). Conclusions: Our results show that Canadian oncology residents’ sense that AI is important and relevant to their area of training. Despite this, they have not received education on these topics. Thus, formalized teaching, such as lectures and workshops, would be perceived as beneficial by most Canadian oncology residents.

Barriers to Access: Global Variability in Implementing Treatment Advances in Lung Cancer

Globally, lung cancer is the second most-diagnosed cancer and is the leading cause of cancer death. Advances in science and technology have contributed to improvements in primary cancer prevention, cancer diagnosis, and cancer therapy, leading to an increase in survival and improvement in quality of life. Many of these advances have been seen in high-income countries. Accessibility, availability, and affordability are key domains in barriers to access of care between countries and within countries. The impact of these domains, as they relate to molecular testing, radiation therapy, and systemic therapy, are discussed.

Recommended first-line management of brain metastases from melanoma: A multicenter survey of clinical practice

BACKGROUND

Radiotherapy (RT) and surgery (Sx) are effective in treating brain metastases. However, immune checkpoint inhibitors (ICI) have shown activity against asymptomatic melanoma brain metastases (MBM). BRAF/MEK inhibitors can be used to treat BRAF V600 mutation positive (BRAF+) MBM.

METHOD

We conducted an international survey among experts from medical oncology (MO), clinical oncology (CO), radiation oncology (RO), and neurosurgery (NS) about treatment recommendations for patients with asymptomatic BRAF+ or BRAF mutation negative (BRAF-) MBM. Eighteen specific clinical scenarios were presented and a total of 267 responses were collected. Answers were grouped and compared using Fisher's exact test.

RESULTS

In most MBM scenarios, survey respondents, regardless of specialty, favored RT in addition to systemic therapy. However, for patients with BRAF+ MBM, MO and CO were significantly more likely than RO and NS to recommend BRAF/MEK inhibitors alone, without the addition of RT, including the majority of MO (51%) for patients with 1-3 MBM, all <2cm. Likewise, for BRAF- MBM, MO and CO more commonly recommended single or dual agent ICI only and dual agent ICI therapy alone was the most common recommendation from MO or CO for MBM <2cm. When at least 1 of 3 MBM (BRAF+ or BRAF-) was >2cm, upfront Sx was recommended by all groups with the exception that MO and RO recommended RT for BRAF- MBM.

CONCLUSIONS

In most clinical settings involving asymptomatic MBM, experts recommended RT in addition to systemic therapy. However, recommendations varied significantly according to specialty, with MO and CO more commonly recommending dual systemic therapy alone for up to 9 BRAF- MBM <2cm.

Tracking the Workforce 2020-2030: Making the Case for a Cancer Workforce Registry

Existing literature has described the projected increase in cancer incidence and the associated deficiencies in the cancer workforce. However, there is currently a lack of research into the necessary policy and planning steps that can be taken to mitigate this issue. Herein, we review current literature in this space and highlight the importance of implementing oncology workforce registries. We propose the establishment of cancer workforce registries using the WHO Minimum Data Set for Health Workforce Registry by adapting the data set to suit the multidisciplinary nature of the cancer workforce. The cancer workforce registry will track the trends of the workforce, so that evidence can drive decisions at the policy level. The oncology community needs to develop and optimize methods to collect information for these registries. National cancer societies are likely to continue to lead such efforts, but ministries of health, licensing bodies, and academic institutions should contribute and collaborate.

Transformational Role of Medical Imaging in (Radiation) Oncology

Simple Summary

Onboard, imaging techniques have brought about a huge transformation in the ability to deliver targeted radiation therapies. Each generation of these technologies enables us to better visualize where to deliver lethal doses of radiation and thus allows the shrinking of necessary geometric margins leading to reduced toxicities. Alongside improvements in treatment delivery, advances in medical imaging have also allowed us to better define the volumes we wish to target. The development of imaging techniques that can capture aspects of the tumor’s biology before, during and after therapy is transforming how treatment can be delivered. Technological changes have further made these biological imaging techniques available in real-time providing the opportunity to monitor a patient’s response to treatment closely and often before any volume changes are visible on conventional radiological images. Here we discuss the development of robust quantitative imaging biomarkers and how they can personalize therapy towards meaningful clinical endpoints.

Abstract

Onboard, real-time, imaging techniques, from the original megavoltage planar imaging devices, to the emerging combined MRI-Linear Accelerators, have brought a huge transformation in the ability to deliver targeted radiation therapies. Each generation of these technologies enables lethal doses of radiation to be delivered to target volumes with progressively more accuracy and thus allows shrinking of necessary geometric margins, leading to reduced toxicities. Alongside these improvements in treatment delivery, advances in medical imaging, e.g., PET, and MRI, have also allowed target volumes themselves to be better defined. The development of functional and molecular imaging is now driving a conceptually larger step transformation to both better understand the cancer target and disease to be treated, as well as how tumors respond to treatment. A biological description of the tumor microenvironment is now accepted as an essential component of how to personalize and adapt treatment. This applies not only to radiation oncology but extends widely in cancer management from surgical oncology planning and interventional radiology, to evaluation of targeted drug delivery efficacy in medical oncology/immunotherapy. Here, we will discuss the role and requirements of functional and metabolic imaging techniques in the context of brain tumors and metastases to reliably provide multi-parametric imaging biomarkers of the tumor microenvironment.

Management of Diffuse Low-Grade Glioma: The Renaissance of Robust Evidence

The surgical management of diffuse low-grade gliomas (DLGGs) has undergone a paradigm shift toward striving for maximal safe resection when feasible. While extensive observational data supports this transition, unbiased evidence in the form of high quality randomized-controlled trials (RCTs) is lacking. Furthermore, despite a high volume of molecular, genetic, and imaging data, the field of neuro-oncology lacks personalized care algorithms for individuals with DLGGs based on a robust foundation of evidence. In this manuscript, we (1) discuss the logistical and philosophical challenges hindering the development of surgical RCTs for DLGGs, (2) highlight the potential impact of well-designed international prospective observational registries, (3) discuss ways in which cutting-edge computational techniques can be harnessed to generate maximal insight from high volumes of multi-faceted data, and (4) outline a comprehensive plan of action that will enable a multi-disciplinary approach to future DLGG management, integrating advances in clinical medicine, basic molecular research and large-scale data mining.

Stereotactic body radiotherapy (SBRT) in metachronous oligometastatic prostate cancer: a systematic review and meta-analysis on the current prospective evidence

OBJECTIVE

In contrast to traditional views of incurability, patients with oligometastatic disease present with an opportunity for disease eradication with aggressive treatment. There is mounting evidence in support of the role of stereotactic body radiotherapy (SBRT) in oligometastatic prostate cancer (OMPC).

METHODS

MEDLINE and EMBASE were queried for prospective cohort studies reporting the outcomes of metachronous OMPC treated with SBRT. The primary outcome was overall local control. Secondary outcomes included androgen deprivation therapy-free survival (ADTFS), biochemical recurrence free survival (BCFS), and progression-free survival (PFS). When appropriate, these endpoints were combined in a meta-analysis.

RESULTS

We screened 356 abstracts and identified 10 studies to include in our analysis, with a total of 653 patients and 1,111 lesions. The maximum number of lesions included in any single study ranged from 3 to 5. PET-CT staging occurred in 92.4% of all patients. SBRT dose varied, with BED_1.5 ranging from 152 to 408. Only one Grade 3 bone toxicity was observed. Meta-analysis reported an overall local control rate of 97% (95% CI, 94-100). Median ADTFS was 24.7 months (95% CI, 20.1-29.2 months). Two-year BCFS, PFS, and ADTFS were 33% (95% CI, 11-55), 39% (95% CI, 24-54), and 52% (95%CI, 41-62), respectively. Patients treated with SBRT were half as likely to experience PSA progression than those on observation when looking at randomized control trial data alone.

CONCLUSION

SBRT appears to be effective in controlling overall disease burden in metachronous OMPC patients and is associated with minimal significant toxicity. The current prospective literature is scarce, and further prospective data are needed to guide treatment recommendations.

ADVANCES IN KNOWLEDGE

This study provides a comprehensive summary of the prospective evidence reporting the outcomes of SBRT in the management of OMPC patients. We quantify the rates of local control, biochemical-free recurrence, progression-free survival, and ADT-free survival through meta-analysis.

Development and validation of a prediction-score model for distant metastases in major salivary gland carcinoma

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Background: We developed and validated a prediction-score for distant metastases (DM) in major salivary gland carcinoma (SGC). Methods: Patients with SGC treated with curative-intent surgery +/- postoperative radiation therapy (PORT) at 4 tertiary cancer centers were divided into discovery (institution A&B) and validation (institution C&D) cohorts. Multivariable analysis using competing risk regression was used to identify predictors of DM in the discovery cohort and create a prediction score. The optimal score cut-off for high vs low-DM risk was determined using a minimal p-value approach. The results were subsequently evaluated in the validation cohort. The cumulative incidence and Kaplan-Meier methods were used to analyze DM and overall survival (OS), respectively. Results: Overall, 1035 patients were included (Table). In the discovery cohort, DM predictors (risk score coefficient) were: positive margin (0.6), pT3-4 (0.7), pN+ (0.7), lymphovascular invasion (LVI; 0.8), and high risk histology* (1.2). High DM-risk SGC was defined by sum of coefficients greater than 2. In the discovery cohort, the 5-year cumulative incidence of DM for high vs low risk SGC was 50% vs 8%; p < 0.01; these results were similar in the validation cohort (44% vs 4% at 5 years; p < 0.01). In the combined cohorts, this model predicted distant-only failure (40% vs 6%, p < 0.01) and late ( > 2yr post surgery) DM (22% vs 4%; p < 0.01). Patients with high DM-risk SGC had an increased incidence of DM in the subgroup receiving PORT (46% vs 8%; p < 0.01) or concurrent chemotherapy (71% vs 34%; p < 0.01). The 5-yr OS for high vs low risk SGC was 48% vs 92% (p < 0.01). Conclusions: This validated prediction score model may be used to identify SGC patients at increased risk for DM and select those who may benefit from prospective evaluation of treatment intensification and/or surveillance strategies. Baseline characteristics. [Table: see text]

Cosmesis in patients with breast neoplasia submitted to the hypofractionated radiotherapy with of intensity-modulated beam

OBJECTIVE

To assess the cosmetic satisfaction of patients diagnosed with breast cancer submitted to the hypofractionated radiotherapy with IMRT (hIMRT) technique and its correlation with dosimetric data of the radiotherapy planning.

METHODS

The retrospective cohort study that assessed women with a diagnosis of malignant breast neoplasia submitted to the conservative treatment or radical mastectomy and treated with hIMRT. In the period between August 2007 to December 2014, in a philanthropic / private institution, 170 records were selected. The cosmetic assessment was carried out by means of the Harvard/RTOG/NSABP scale with one-year minimum range after treatment. The collected dosimetric data were: breast / chest wall volume, volume that received 95% (V95%) and 107% (V107%) of the prescribed dose.

RESULTS

The volume of the treated breasts ranged from 169 to 2.103 ml (median = 702; IQR: 535 to 914 ml). Median V95% was 86.7% (54.6-96.6%; IQR: 80.0% to 90.6%); eight (5.7%) patients had V95% higher than 95%. Median V107% was 0% (0%-16.3%; IQR: 0.0% to 0.3% and 13); 9.3% patients had V107% higher than 2%. One hundred and thirty-three (78.2%) patients responded to the cosmetic assessment: 99 (74.4%) considered the cosmetic results excellent. Significant associations between cosmetic assessment and breast volume (p=0.875), V95% (p=0.294) e V107% (p=0.301) were not found.

CONCLUSION

The cosmetic results showed favorable when using hIMRT, and the lack of correlation with usual the dosimetric data illustrates the capacity of hIMRT to minimize the heterogeneity of the dose in this endpoint, even in voluminous breasts.

Toxicity of Radiosurgery for Brainstem Metastases

BACKGROUND

Although stereotactic radiosurgery (SRS) is an effective modality in the treatment of brainstem metastases (BSM), radiation-induced toxicity remains a critical concern. To better understand how severe or life-threatening toxicity is affected by the location of lesions treated in the brainstem, a review of all available studies reporting SRS treatment for BSM was performed.

METHODS

Twenty-nine retrospective studies investigating SRS for BSM were reviewed.

RESULTS

The rates of grade 3 or greater toxicity, based on the Common Terminology Criteria for Adverse Events, varied from 0 to 9.5% (mean 3.4 ± 2.9%). Overall, the median time to toxicity after SRS was 3 months, with 90% of toxicities occurring before 9 months. A total of 1243 cases had toxicity and location data available. Toxicity rates for lesions located in the medulla were 0.8% (1/131), compared with midbrain and pons, respectively, 2.8% (8/288) and 3.0% (24/811).

CONCLUSIONS

Current data suggest that brainstem substructure location does not predict for toxicity and lesion volume within this cohort with median tumor volumes 0.04-2.8 cc does not predict for toxicity.

Long-term outcomes of dose-escalated intensity modulated radiation therapy alone without androgen deprivation therapy for patients with intermediate and high-risk prostate cancer

Objective

The addition of androgen deprivation therapy (ADT) to conventional radiation therapy improves overall survival (OS) in intermediate- and high-risk prostate cancer. The benefit of ADT to added to dose-escalated radiotherapy is less clear. The aim of this study was to report disease control outcomes and to identify prognostic variables associated with favorable outcomes in patients with intermediate- and high-risk prostate cancer treated with dose-escalated radiation therapy without ADT.

Methods and materials

From September 2001 to March 2010, 127 patients with intermediate- or high-risk prostate cancer were treated with dose-escalated radiation otherapy without ADT. Biochemical recurrence-free survival (bRFS), distant metastases-free survival (DMFS), prostate cancer–specific mortality, and OS were assessed. Univariate and multivariate analyses using Cox regression modeling were performed.

Results

The median follow-up was 6.5 years, and the 5-year estimated bRFS, DMFS, prostate cancer–specific mortality, and OS for all patients was 89%, 96.1%, 98.4%, and 96.9% respectively. On multivariate analysis, factors that predict bRFS include risk group and PSA nadir, and factors that predict DMFS include perineural invasion, risk group, and PSA nadir.

Conclusions

Patients with favorable intermediate-risk cancer could likely be treated with dose-escalated radiation therapy without ADT. Patients with high-risk and unfavorable intermediate-risk cancer, perineural invasion, and PSA nadir ≥1ng/dL had worse outcomes and likely need distinct therapeutic approaches.

Spine radiosurgery for the local treatment of spine metastases: Intensity-modulated radiotherapy, image guidance, clinical aspects and future directions

Many cancer patients will develop spinal metastases. Local control is important for preventing neurologic compromise and to relieve pain. Stereotactic body radiotherapy or spinal radiosurgery is a new radiation therapy technique for spinal metastasis that can deliver a high dose of radiation to a tumor while minimizing the radiation delivered to healthy, neighboring tissues. This treatment is based on intensity-modulated radiotherapy, image guidance and rigid immobilization. Spinal radiosurgery is an increasingly utilized treatment method that improves local control and pain relief after delivering ablative doses of radiation. Here, we present a review highlighting the use of spinal radiosurgery for the treatment of metastatic tumors of the spine. The data used in the review were collected from both published studies and ongoing trials. We found that spinal radiosurgery is safe and provides excellent tumor control (up to 94% local control) and pain relief (up to 96%), independent of histology. Extensive data regarding clinical outcomes are available; however, this information has primarily been generated from retrospective and nonrandomized prospective series. Currently, two randomized trials are enrolling patients to study clinical applications of fractionation schedules spinal Radiosurgery. Additionally, a phase I clinical trial is being conducted to assess the safety of concurrent stereotactic body radiotherapy and ipilimumab for spinal metastases. Clinical trials to refine clinical indications and dose fractionation are ongoing. The concomitant use of targeted agents may produce better outcomes in the future.

Postoperative nodal irradiation in breast cancer patients with 1 to 3 axillary lymph nodes involved: the debate continues…

Regional lymph node irradiation is usually indicated in patients with positive node breast cancer. However, there are some controversies regarding the clinical benefits of adding regional nodal irradiation to whole-breast or thoracic-wall irradiation after breast surgery especially for patients with 1 to 3 positive axillary lymph nodes. More recently, two important studies (NCIC MA.20 and EORTC 22,922-10925) were published to address this significant issue and some further points need to be discussed.

Stereotactic body radiotherapy in lung cancer: an update

For early-stage lung cancer, the treatment of choice is surgery. In patients who are not surgical candidates or are unwilling to undergo surgery, radiotherapy is the principal treatment option. Here, we review stereotactic body radiotherapy, a technique that has produced quite promising results in such patients and should be the treatment of choice, if available. We also present the major indications, technical aspects, results, and special situations related to the technique.

Literature review of clinical results of total skin electron irradiation (TSEBT) of mycosis fungoides in adults

BACKGROUND

Mycosis fungoides (MF) is an extranodal, indolent non-Hodgkin lymphoma of T cell origin. Even with the establishment of MF staging, the initial treatment strategy often remains unclear.

AIM

The aim of this study was to review the clinical results of total skin electron beam therapy (TSEBT) for MF in adults published in English language scientific journals searched in Pubmed/Medline database until December 2012.

RESULTS

MF is very sensitive to radiation therapy (RT) delivered either by photons or by electrons. In limited patches and/or plaques local electron beam irradiation results in good outcomes besides the fact of not being superior to other modalities. For extensive patches and/or plaques data suggest that TSEBT shows superior response rates. The cutaneous disease presentation is favorably managed with radiotherapy due to its ability to treat the full thickness of deeply infiltrated skin. For generalized erythroderma presentation, TSEBT seems to be an appropriate initial therapy. For advanced disease, palliation, or recurrence after the first radiotherapy treatment course, TSEBT may still be beneficial, with acceptable toxicity. Recommended dose is 30-36 Gy delivered in 6-10 weeks.

CONCLUSION

TSEBT can be used to treat any stage of MF. It also presents good tumor response with symptoms of relief and a palliative effect on MF, either after previous irradiation or failure of other treatment strategies.