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Cheng JC, Buduhan G, Venkataraman S, Tan L, Sasaki D, Bashir B, Ahmed N, Kidane B, Sivananthan G, Koul R, Leylek A, Butler J, McCurdy B, Wong R, Kim JO. Endobronchially Implanted Real-Time Electromagnetic Transponder Beacon-Guided, Respiratory-Gated SABR for Moving Lung Tumors: A Prospective Phase 1/2 Cohort Study. Adv Radiat Oncol 2023; 8:101243. [PMID: 37408673 PMCID: PMC10318214 DOI: 10.1016/j.adro.2023.101243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/03/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose Endobronchial electromagnetic transponder beacons (EMT) provide real-time, precise positional data of moving lung tumors. We report results of a phase 1/2, prospective, single-arm cohort study evaluating the treatment planning effects of EMT-guided SABR for moving lung tumors. Methods and Materials Eligible patients were adults, Eastern Cooperative Oncology Group 0 to 2, with T1-T2N0 non-small cell lung cancer or pulmonary metastasis ≤4 cm with motion amplitude ≥5 mm. Three EMTs were endobronchially implanted using navigational bronchoscopy. Four-dimensional free-breathing computed tomography simulation scans were obtained, and end-exhalation phases were used to define the gating window internal target volume. A 3-mm expansion of gating window internal target volume defined the planning target volume (PTV). EMT-guided, respiratory-gated (RG) SABR was delivered (54 Gy/3 fractions or 48 Gy/4 fractions) using volumetric modulated arc therapy. For each RG-SABR plan, a 10-phase image-guided SABR plan was generated for dosimetric comparison. PTV/organ-at-risk (OAR) metrics were tabulated and analyzed using the Wilcoxon signed-rank pair test. Treatment outcomes were evaluated using RECIST (Response Evaluation Criteria in Solid Tumours; version 1.1). Results Of 41 patients screened, 17 were enrolled and 2 withdrew from the study. Median age was 73 years, with 7 women. Sixty percent had T1/T2 non-small cell lung cancer and 40% had M1 disease. Median tumor diameter was 1.9 cm with 73% of targets located peripherally. Mean respiratory tumor motion was 1.25 cm (range, 0.53-4.04 cm). Thirteen tumors were treated with EMT-guided SABR and 47% of patients received 48 Gy in 4 fractions while 53% received 54 Gy in 3 fractions. RG-SABR yielded an average PTV reduction of 46.9% (P < .005). Lung V5, V10, V20, and mean lung dose had mean relative reductions of 11.3%, 20.3%, 31.1%, and 20.3%, respectively (P < .005). Dose to OARs was significantly reduced (P < .05) except for spinal cord. At 6 months, mean radiographic tumor volume reduction was 53.5% (P < .005). Conclusions EMT-guided RG-SABR significantly reduced PTVs of moving lung tumors compared with image-guided SABR. EMT-guided RG-SABR should be considered for tumors with large respiratory motion amplitudes or those located in close proximity to OARs.
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Affiliation(s)
- Jui Chih Cheng
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gordon Buduhan
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Lawrence Tan
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Sasaki
- Medical Physics, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Bashir Bashir
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Naseer Ahmed
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Biniam Kidane
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gokulan Sivananthan
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rashmi Koul
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ahmet Leylek
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James Butler
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Boyd McCurdy
- Medical Physics, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Ralph Wong
- Medical Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julian O. Kim
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- CancerCare Manitoba Research Institute, Winnipeg, Manitoba, Canada
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Venugopal B, Shahhat S, Beck J, Hanumanthappa N, Ong AD, Dubey A, Koul R, Bashir B, Chowdhury A, Sivananthan G, Kim JO. Factors Associated with Long-Term Prostate Cancer Survival after Palliative Radiotherapy to a Bone Metastasis and Contemporary Palliative Systemic Therapy: A Retrospective, Population-Based Study. Curr Oncol 2023; 30:5560-5573. [PMID: 37366903 DOI: 10.3390/curroncol30060420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Radiation therapy (RT) is an established palliative treatment for bone metastases; however, little is known about post-radiation survival and factors which impact it. The aim of this study was to assess a population-based sample of metastatic prostate cancer patients receiving palliative radiation therapy to bone metastases and contemporary palliative systemic therapy and identify factors that impact long-term survival. MATERIALS/METHODS This retrospective, population-based, cohort study assessed all prostate cancer patients receiving palliative RT for bone metastases at a Canadian provincial Cancer program during a contemporary time period. Baseline patient, disease, and treatment characteristics were extracted from the provincial medical physics databases and the electronic medical record. Post-RT Survival intervals were defined as the time interval from the first fraction of palliative RT to death from any cause or date of the last known follow-up. The median survival of the cohort was used to dichotomize the cohort into short- and long-term survivors following RT. Univariable and multivariable hazard regression analyses were performed to identify variables associated with post-RT survival. RESULTS From 1 January 2018 until 31 December 2019, 545 palliative RT courses for bone metastases were delivered to n = 274 metastatic prostate cancer patients with a median age of 76 yrs (Interquartile range (IQR) 39-83) and a median follow-up of 10.6 months (range 0.2 to 47.9). The median survival of the cohort was 10.6 months (IQR 3.5-25 months). The ECOG performance status of the whole cohort was ≤2 in n = 200 (73%) and 3-4 in n = 67 (24.5%). The most commonly treated sites of bone metastasis were the pelvis and lower extremities n = 130 (47.4%), skull and spine n = 114 (41.6%), and chest and upper extremities n = 30 (10.9%). Most patients had CHAARTED high volume disease n = 239 (87.2%). On multivariable hazard regression analysis, an ECOG performance status of 3-4 (p = 0.02), CHAARTED high volume disease burden (p = 0.023), and non-receipt of systemic therapy (p = 0.006) were significantly associated with worse post-RT survival. CONCLUSION Amongst metastatic prostate cancer patients treated with palliative radiotherapy to bone metastases and modern palliative systemic therapies, ECOG performance status, CHAARTED metastatic disease burden, and type of first-line palliative systemic therapy were significantly associated with post-RT survival durations.
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Affiliation(s)
- Bindu Venugopal
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
- Department of Radiation Oncology, Kidwai Memorial Institute of Oncology, Bangalore 560029, India
| | - Shaheer Shahhat
- Department of Radiation Oncology, Western University, London, ON N6A 5W9, Canada
| | - James Beck
- Department of Medical Physics, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Nikesh Hanumanthappa
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
- Department of Radiation Oncology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai 400053, India
| | - Aldrich D Ong
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Arbind Dubey
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Rashmi Koul
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Bashir Bashir
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Amitava Chowdhury
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Gokulan Sivananthan
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Julian Oliver Kim
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
- CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
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Antony F, Shrivastav A, Dubey A, Usmani N, Ong A, Koul R, Quon H, Sivananthan G, Hunter W, Yee D, Rowe L, Danielson B, Plesniarski A, Su RC, Kim JO. Abstract 4858: Effect of mTOR activity in peripheral blood mononuclear cells with metformin in high-risk prostate cancer patients receiving external beam radiotherapy and androgen deprivation therapy. Cancer Res 2023. [DOI: 10.1158/1538-7445.am2023-4858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Abstract
Introduction: There is considerable interest in the antineoplastic properties of metformin for prostate cancer treatment, however, the underlying mechanism of action of metformin in this setting is poorly understood. It is suspected that metformin’s antineoplastic activity is related to inhibition of mTOR (mammalian target of rapamycin), which ultimately inhibits cell proliferation. In this pilot study, we assessed the mTOR activity of peripheral blood mononuclear cells (PBMCs) from high-risk Prostate cancer (PCa) patients treated with androgen deprivation therapy (ADT) and external beam radiotherapy (EBRT) plus metformin versus placebo. We hypothesized decreased mTOR expression in PBMCs from patients receiving metformin versus placebo.
Methods: Normoglycemic adult males with high-risk PCa receiving ADT & EBRT were randomized to metformin 500 mg 3 times daily or placebo. Peripheral blood samples were collected from participants
≥ 6 months after starting study drug, buffy coats were extracted, and PBMCs were isolated ≤2 hours after specimen collection using ficoll-hypaque density gradient method. The mTOR expression was assessed by phosphorylation of serine 2448 (pmTOR; S2448). Activity of mTOR was measured in both unstimulated or stimulated (using CD3/CD28 antibodies) CD4+ and CD8+ T cells.
Results: Samples from 15 patients were analyzed (11 placebo & 4 metformin). We observed lower expression of pmTOR in PBMCs in patients receiving metformin compared to placebo indicating metformin demonstrated inhibition of mTOR activity in PBMCs. A general trend of mTOR inhibition was observed in the metformin group across the cell population and conditions (unstimulated vs. stimulated T cell populations). However, the most pronounced difference was observed in unstimulated CD4+ cells, which is of interest since they represent the closest physiological state to the study participants.
Conclusion: In this pilot study, we observed mTOR inhibition in the PBMCs of PCa patients treated with metformin. Further assessment of mTOR activity amongst PCa patients receiving metformin is warranted in order to confirm these findings.
Citation Format: Febin Antony, Anuraag Shrivastav, Arbind Dubey, Nawaid Usmani, Aldrich Ong, Rashmi Koul, Harvey Quon, Gokulan Sivananthan, William Hunter, Don Yee, Lindsay Rowe, Brita Danielson, Andrew Plesniarski, Ruey-Chyi Su, Julian O. Kim. Effect of mTOR activity in peripheral blood mononuclear cells with metformin in high-risk prostate cancer patients receiving external beam radiotherapy and androgen deprivation therapy. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4858.
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Affiliation(s)
- Febin Antony
- 1Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | | | - Arbind Dubey
- 1Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | | | - Aldrich Ong
- 1Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Rashmi Koul
- 1Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Harvey Quon
- 4Tom Baker Cancer Center, Calgary, Alberta, Canada
| | | | | | - Don Yee
- 5Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Lindsay Rowe
- 5Cross Cancer Institute, Edmonton, Alberta, Canada
| | | | - Andrew Plesniarski
- 6JC Wilt Infectious Diseases Research Centre, Winnipeg, Manitoba, Canada
| | - Ruey-Chyi Su
- 6JC Wilt Infectious Diseases Research Centre, Winnipeg, Manitoba, Canada
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Carrato K, Jain N, Eckert A, Lamberti M, Sutton C, Sens J, Horton K, Khan A, Tabori N, Sivananthan G, Smirniotopoulos J. Abstract No. 120 Genicular Nerve Radiofrequency Ablation: Is There a Predictor of Outcomes? J Vasc Interv Radiol 2023. [DOI: 10.1016/j.jvir.2022.12.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
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Usmani N, Ghosh S, Sanghera KP, Ong AD, Koul R, Dubey A, Ahmed S, Quon H, Yee D, Parliament M, Sivananthan G, Hunter W, Danielson B, Rowe L, McDonald M, Kim JO. Metformin for Prevention of Anthropometric and Metabolic Complications of Androgen Deprivation Therapy in Prostate Cancer Patients Receiving Radical Radiotherapy: A Phase II Randomized Controlled Trial. Int J Radiat Oncol Biol Phys 2023; 115:317-326. [PMID: 35907513 DOI: 10.1016/j.ijrobp.2022.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/02/2022] [Accepted: 07/18/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Patients with prostate cancer undergoing treatment with radical radiation therapy (RT) plus androgen deprivation therapy (ADT) experience a constellation of deleterious metabolic and anthropometric changes related to hypogonadism that are associated with increased morbidity and mortality. We assessed the effect of metformin versus placebo to blunt the adverse effects of ADT on body weight, waist circumference, and other metabolic parameters. METHODS AND MATERIALS This phase 2, multicenter, randomized controlled trial (RCT) randomized normoglycemic men with locally advanced prostate cancer receiving radical RT and ADT (18-36 months) in a 1:1 ratio to receive metformin 500 mg by mouth 3 times a day (for 30-36 months) versus identical placebo. RESULTS From December 2015 to October 2019, 83 men were randomized with median follow-up of 23 months. Baseline mean body mass Index (BMI) of the cohort was 30.2 (range 22.2-52.5). Change in mean weight relative to baseline was lower among men who received metformin compared with placebo at 5 months (-1.80 kg, P = .038), but was not significant with longer follow-up (1 year: +0.16 kg, P = .874). Although participants on ADT had increases in waist circumference in both study arms, metformin did not significantly reduce these changes (1 year: +2.79 cm (placebo) versus +1.46 cm (metformin), P = .336). Low-density lipoprotein (LDL) cholesterol was lower in the metformin arm (-0.32 mmol/L) compared with the placebo arm (-0.03 mmol/L) at 5 months (P = .022), but these differences were not significant with longer follow-up (1 year: -0.17 mmol/L vs -0.19 mmol/L, P = .896). There were no differences in HbA1C, triglyceride, high-density lipoprotein (HDL) cholesterol, and total cholesterol by study arm. CONCLUSIONS Men receiving radical RT and ADT gained weight and had increases in waist circumference over time that metformin did not significantly mitigate. Although this study did not observe any preventive effect of metformin on the anthropometric and metabolic complications of ADT, metformin continues to be studied in phase 3 RCTs in this patient population to assess its potential antineoplastic effects.
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Affiliation(s)
- Nawaid Usmani
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Division of Experimental Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Karan P Sanghera
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Aldrich D Ong
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Heath Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rashmi Koul
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Heath Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arbind Dubey
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Heath Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shahida Ahmed
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Heath Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harvey Quon
- Division of Radiation Oncology, Tom Baker Cancer Center, University of Calgary, Calgary, Alberta, Canada
| | - Don Yee
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Matthew Parliament
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Gokulan Sivananthan
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Heath Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Western Manitoba Cancer Centre, Brandon, Manitoba, Canada
| | - William Hunter
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Heath Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Western Manitoba Cancer Centre, Brandon, Manitoba, Canada
| | - Brita Danielson
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Lindsay Rowe
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Megan McDonald
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Heath Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julian O Kim
- Section of Radiation Oncology, Department of Radiology, Max Rady Faculty of Heath Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; CancerCare Manitoba Research Institute, Winnipeg, Manitoba, Canada.
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Alfaifi S, Kim J, Rathod S, Hunter W, Leylek A, Ahmed N, Venkataraman S, Venugopal N, Kane B, Chowdhury A, Dubey A, Sivananthan G, Kakumanu S, Bashir B. Implementation and Safety of a Single Fraction Peripheral Lung SBRT during the Global COVID-19 Pandemic, a Single Institution's Experience. Int J Radiat Oncol Biol Phys 2022. [PMCID: PMC9595454 DOI: 10.1016/j.ijrobp.2022.07.1480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Purpose/Objective(s) In response to the COVID-19 pandemic, a single fraction peripheral lung SBRT program was established to minimize potential COVID-19 exposures. This analysis aims to review clinical and treatment characteristics and associated toxicities in appropriately selected patients for this newly implemented technique. Materials/Methods From May 2020 until Feb 2022, patients with peripheral lung tumors who met eligibility for 3400cGy in a single-fraction SBRT were treated at a tertiary academic cancer center. Patient, treatment, and toxicity parameters were retrospectively collected. Radiation dosimetric parameters were tabulated. Toxicities were quantified using CTCAE v5.0. Fisher's exact test was used to assess the differences in toxicities with clinical and dosimetric parameters. P-value < 0.05 was considered significant. Results 23 patients were analyzed with a median age of 72 years (IRQ: 67-80) and 61% were females. 96% were smokers and 43% had COPD. All patients were ECOG ≤ 2. Majority of patients (96%) had early-stage primary lung cancer while 4% had pulmonary oligometastatic cancer. 39% of patients were treated on SABR-BRIDGE protocol while another 35% were medically inoperable and 26% refused surgery. A total of 23 peripheral lesions were treated with median greatest dimension of 1.7 cm (IQR: 1.4-2), ITV 4.9 cm3 (IQR: 3.6-8.4) and PTV 18.1 cm3 (IQR: 12.8-26). 87% had PTV within 1 cm form chest wall. After median follow-up of 6 months (IQR: 2-12), 52% of patients experienced grade ≤ 2 toxicities and no patients experienced ≥ grade 3. Radiation pneumonitis was the most common toxicity (35%; 5/8 with asymptomatic radiographic) followed by fatigue (30%) and chest wall pain (30%; 3/7 with grade 2). Two patients (9%) had rib fractures. Chest wall pain was significantly higher in patients with tumor diameter >1.5 cm (p = 0.02). No other significant difference was observed between clinical or dosimetric parameters and development of radiation pneumonitis or chest wall pain (p > 0.05). On the other hand, patients with ribs fractures were observed to have larger tumors (mean 3.2 vs. 1.7 cm), ITVs (mean 30 vs. 11 cm3), PTVs (mean 61 vs. 16 cm3), chest wall V30Gy (mean 4.8 vs. 0.4 cm3), and ribs V30Gy (mean 1.1 vs. 0.1 cm3). Only 1 patient had local failure after 12 months while another patient on SABR-BRIDGE underwent surgical resection after 6 months in which there were 20% viable tumor cells. Conclusion Single fraction peripheral lung SBRT is a practical and safe option with no grade ≥ 3 toxicity. Our observed toxicities are within previously reported ranges. We observed that patients with rib fractures had larger tumors and higher V30Gy to chest wall and ribs. Careful patient selection and dosimetric efforts to limit high fall-off dose to chest wall and ribs may limit these toxicities.
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Affiliation(s)
- S. Alfaifi
- Postgraduate Medical Education, School of Medicine, University of Manitoba, Winnipeg, MB, Canada,Corresponding author
| | - J. Kim
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - S. Rathod
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - W. Hunter
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - A. Leylek
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - N. Ahmed
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - S. Venkataraman
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - N. Venugopal
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - B. Kane
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - A.D. Chowdhury
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - A. Dubey
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - G. Sivananthan
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - S.A. Kakumanu
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - B.M. Bashir
- Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
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Cheng J, Buduhan G, Venkataraman S, Bashir B, Ahmed N, Tan L, Kidane B, Sasaki D, Rathod S, Sivananthan G, Koul R, Leylek A, Butler J, McCurdy B, Kim J. Endobronchial Implanted Real-Time Radiofrequency (RF) Transponder Beacon Guided, Respiratory-Gated, Stereotactic Body Radiotherapy for Moving Lung Tumors: Interim Analysis of a Prospective Phase I/II Cohort Study. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Alfaifi S, Kim J, Rathod S, Hunter W, Leylek A, Ahmed N, Venkataraman S, Venugopal N, Kane B, Chowdhury A, Dubey A, Sivananthan G, Kakumanu S, Bashir B. 31: Single Fraction Peripheral Lung SBRT During the Global COVID-19 Pandemic at a Cancercare Manitoba: An Analysis of Technical Feasibility and Clinical Safety. Radiother Oncol 2022. [PMCID: PMC9500567 DOI: 10.1016/s0167-8140(22)04310-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cheng JC, Venkataraman S, Ahmed N, Tan L, Kidane B, Sasaki D, Rathod S, Sivananthan G, Koul R, Leylek A, Butler J, McCurdy B, Wong R, Kim J. 100: Endobronchial Implanted Real-Time Radiofrequency (Rf) Transponder Beacon Guided, Respiratory-Gated, Stereotactic Body Radiotherapy for Moving Lung Tumours: Interim Analysis of a Prospective Phase I/ II Cohort Study. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)04379-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Venugopal B, Shahhat S, Beck J, Hanumanthappa N, Ong A, Dubey A, Koul R, Bashir B, Chowdhury A, Sivananthan G, Kim J. 168: Identification of Factors Associated with Prolonged Survival in Prostate Cancer Patients Post-Receipt of Palliative Radiotherapy to a Bone Metastasis: A Retrospective, Population-Based Study. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)04448-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Jain N, Frenk N, Sivananthan G, Smirniotopoulos J. Abstract No. 217 Safety and efficacy of percutaneous fluoroscopic-guided large bore gallstone extraction. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kim JO, McDonald MO, Ong A, Koul R, Dubey A, Hunter W, Ahmed S, Quon H, Yee D, Parliament M, Sivananthan G, Danielson B, Rowe L, Ghosh S, Usmani N. Gastrointestinal and genitourinary toxicity profiles of metformin versus placebo in men with prostate cancer receiving prostate radiotherapy: interim toxicity results of a double-blinded, multicenter, phase II randomized controlled trial. Radiat Oncol 2021; 16:212. [PMID: 34736499 PMCID: PMC8567697 DOI: 10.1186/s13014-021-01935-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 10/20/2021] [Indexed: 11/13/2022] Open
Abstract
Androgen deprivation therapy (ADT) used for prostate cancer (PCa) management is associated with metabolic and anthropometric toxicity. Metformin given concurrent to ADT is hypothesized to counteract these changes. This planned interim analysis reports the gastrointestinal and genitourinary toxicity profiles of PCa patients receiving ADT and prostate/pelvic radiotherapy plus metformin versus placebo as part of a phase 2 randomized controlled trial. Men with intermediate or high-risk PCa were randomized 1:1 to metformin versus placebo. Both groups were given ADT for 18–36 months with minimum 2-month neoadjuvant phase prior to radiotherapy. Acute gastrointestinal and genitourinary toxicities were quantified using CTCAE v4.0. Differences in ≥ grade 2 toxicities by treatment were assessed by chi-squared test. 83 patients were enrolled with 44 patients randomized to placebo and 39 randomized to metformin. There were no significant differences at any time point in ≥ grade 2 gastrointestinal toxicities or overall gastrointestinal toxicity. Overall ≥ grade 2 gastrointestinal toxicity was low prior to radiotherapy (7.9% (placebo) vs. 3.1% (metformin), p = 0.39) and at the end of radiotherapy (2.8% (placebo) vs 3.1% (metformin), p = 0.64). There were no differences in overall ≥ grade 2 genitourinary toxicity between treatment arms (19.0% (placebo) vs. 9.4% (metformin), p = 0.30). Metformin added to radiotherapy and ADT did not increase rates of ≥ grade 2 gastrointestinal or genitourinary toxicity and is generally safe and well-tolerated.
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Affiliation(s)
- Julian O Kim
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. .,CancerCare Manitoba Research Institute, CancerCare Manitoba, 675 McDermot Ave, Winnipeg, Manitoba, R3E 0V9, Canada.
| | - Megan O McDonald
- Postgraduate Medical Education, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Aldrich Ong
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rashmi Koul
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arbind Dubey
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - William Hunter
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Western Manitoba Cancer Center, Brandon, Manitoba, Canada
| | - Shahida Ahmed
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harvey Quon
- Division of Radiation Oncology, Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Don Yee
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew Parliament
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Gokulan Sivananthan
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Western Manitoba Cancer Center, Brandon, Manitoba, Canada
| | - Brita Danielson
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsay Rowe
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Nawaid Usmani
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
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Sanghera K, Kim J, Ghosh S, McDonald M, Ong A, Koul R, Dubey A, Ahmed S, Quon H, Yee D, Sivananthan G, Danielson B, Rowe L, Rose J, Hunter W, Usmani N. Interim Analysis of a Phase II Multi-institution Randomized Placebo-controlled Trial the PREMIUM trial (PREvention of Metabolic Syndrome and Increased weight Using Metformin concurrent to ADT and EBRT for locally advanced adenocarcinoma of the prostate). Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.2104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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McDonald MO, Usmani N, Ong A, Koul R, Dubey A, Ahmed S, Quon H, Yee D, Parliament M, Sivananthan G, Danielson B, Rowe L, Rose J, Hunter W, Sanghera KP, Ghosh S, Kim JO. 2: Acute and Subacute Gastrointestinal and Genitourinary Toxicity Profiles of Metformin Versus Placebo Plus Prostate and Pelvic Radiotherapy for the Management of High Risk Prostate Cancer: Interim Toxicity Results of a Double-Blinded, Multicentre, Phase Ii Randomized Controlled Trial. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(20)30894-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Rathod S, Dubey A, Bashir B, Sivananthan G, Leylek A, Chowdhury A, Koul R. Bracing for impact with new 4R's in the COVID-19 pandemic - A provincial thoracic radiation oncology consensus. Radiother Oncol 2020; 149:124-127. [PMID: 32342864 PMCID: PMC7141475 DOI: 10.1016/j.radonc.2020.03.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 01/08/2023]
Abstract
As COVID-19 pandemic continues to explode, cancer centers worldwide are trying to adapt and are struggling with this constantly changing scenario. Intending to ensure patient safety and deliver quality care, we sought consensus on the preferred thoracic radiation regimen in a Canadian province with 4 new R's of COVID era.
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Affiliation(s)
- Shrinivas Rathod
- CancerCare Manitoba and University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Arbind Dubey
- CancerCare Manitoba and University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bashir Bashir
- CancerCare Manitoba and University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Ahmet Leylek
- CancerCare Manitoba and University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amitava Chowdhury
- CancerCare Manitoba and University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rashmi Koul
- CancerCare Manitoba and University of Manitoba, Winnipeg, Manitoba, Canada
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Swanson H, Tabori N, Sabri S, Horton K, Khan A, Sivananthan G. 3:00 PM Abstract No. 182 Effect of intra-arterial nitroglycerin and verapamil administration during radial artery access on systemic blood pressure and its correlation with timing of moderate sedation administration. J Vasc Interv Radiol 2020. [DOI: 10.1016/j.jvir.2019.12.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abdalmassih M, Sivananthan G, Raizman Z, Lambert P, Wirtzfeld D, Bashir B, Wightman R, Daniel K, Nashed M. Prognostic markers of recurrence and survival in rectal cancer treated with neoadjuvant chemoradiotherapy and surgery. Colorectal Cancer 2018. [DOI: 10.2217/crc-2017-0015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: To identify markers of recurrence and survival in patients with locally advanced rectal cancer who received neoadjuvant chemoradiotherapy and surgery. Materials & methods: A total of 280 patients were identified in Manitoba between 2007 and 2012. Demographics and clinical data were collected. Cox regression models were used to identify outcome predictors. Results: A total of 53 patients achieved pathological complete response (pCR) and 160 patients received adjuvant chemotherapy (ACT). The median follow-up duration was 2.06 years. Recurrence and survival rates at 5 years were 33.2 and 77.0%, respectively. pCR and lymphovascular invasion predicted recurrence. pCR and ACT predicted better survival. Conclusion: pCR is a significant predictor of recurrence and survival and may be considered as an oncological end point. The patients who achieve pCR may not derive additional survival benefit from ACT.
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Affiliation(s)
- Michael Abdalmassih
- Cancer Care Manitoba, Radiation Oncology, 675 McDermot Ave, Winnipeg, MB, R3E 0V9, Canada
| | - Gokulan Sivananthan
- Cancer Care Manitoba, Radiation Oncology, 675 McDermot Ave, Winnipeg, MB, R3E 0V9, Canada
| | - Zachary Raizman
- Cancer Care Manitoba, Radiation Oncology, 675 McDermot Ave, Winnipeg, MB, R3E 0V9, Canada
| | - Pascal Lambert
- Cancer Care Manitoba, Epidemiology & Cancer Registry, Winnipeg, MB, Canada
| | - Debrah Wirtzfeld
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, R3T 2N2, Canada
| | - Bashir Bashir
- Cancer Care Manitoba, Radiation Oncology, 675 McDermot Ave, Winnipeg, MB, R3E 0V9, Canada
- Department of Radiology, University of Manitoba, Radiology, Winnipeg, MB, Canada
| | - Robert Wightman
- Department of Pathology, University of Manitoba, Pathology, Winnipeg, MB, Canada
| | - Kroeker Daniel
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, R3T 2N2, Canada
| | - Maged Nashed
- Cancer Care Manitoba, Radiation Oncology, 675 McDermot Ave, Winnipeg, MB, R3E 0V9, Canada
- Department of Radiology, University of Manitoba, Radiology, Winnipeg, MB, Canada
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Abdalmassih M, Raizman Z, Sivananthan G, Kroeker D, Lambert P, Wirtzfeld D, Wightman R, Nashed M. Prognostic markers of tumour recurrence and survival of patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy and radical surgery: A retrospective study. Ann Oncol 2017. [DOI: 10.1093/annonc/mdx261.362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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19
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Nashed M, Raizman Z, Sivananthan G, Kroeker D, Lambert P, Wirtzfeld D, Wightman R. 133: Predictors of Nodal Response after Neoadjuvant Chemoradiotherapy for Rectal Adenocarcinoma; A Retrospective Study. Radiother Oncol 2016. [DOI: 10.1016/s0167-8140(16)33532-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sivananthan G, Menashe L, MacArthur D, Marcus R, Halin N. Cephalic arch stenosis in hemodialysis patients: what is the cephalic arch and does the precise location of stenosis effect patency? J Vasc Interv Radiol 2014. [DOI: 10.1016/j.jvir.2013.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Hakham S, Sivananthan G, De Moor M, Rosen N, Halin N. Deciphering the role of endovascular techniques in the management of adult coarctation of the aorta: a systematic review. J Vasc Interv Radiol 2014. [DOI: 10.1016/j.jvir.2013.12.413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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22
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Sisler JJ, DeCarolis M, Robinson D, Sivananthan G. Family physicians who have focused practices in oncology: results of a national survey. Can Fam Physician 2013; 59:e290-e297. [PMID: 23766068 PMCID: PMC3681472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To characterize the demographic characteristics, practice profile, and current work life of general practitioners in oncology (GPOs) for the first time. DESIGN National Web survey performed in March 2011. SETTING Canada. PARTICIPANTS Members of the national GPO organization. Respondents were asked to forward the survey to non-member colleagues. MAIN OUTCOME MEASURES Profile of work as GPOs and in other medical roles, training received, demographic characteristics, and professional satisfaction. RESULTS The response rate was 73.3% for members of the Canadian Association of General Practitioners in Oncology; overall, 120 surveys were completed. Respondents worked in similar proportions in small and larger communities. About 60% of them had participated in formal training programs. Most respondents worked part-time as GPOs and also worked in other medical roles, particularly palliative care, primary care practice, teaching, and hospital work. More GPOs from cities with populations of greater than 100 000 worked solely as GPOs than those from smaller communities (P = .0057). General practitioners in oncology played a variety of roles in the cancer care system, particularly in systemic therapy, palliative care, inpatient care, and teaching. As a group, more than half of respondents were involved in the care of each of the 11 common cancer types. Overall, 87.8% of respondents worked in outpatient care, 59.1% provided inpatient care, and 33.0% provided on-call services; 92.8% were satisfied with their work as GPOs. CONCLUSION General practitioners in oncology are involved in all cancer care settings and usually combine this work with other roles, particularly with palliative care in rural Canada. Training is inconsistent but initiatives are under way to address this. Job satisfaction is better than that of Canadian FPs in general. As generalists, FPs bring a valuable skill set to their work as GPOs in the cancer care system.
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Affiliation(s)
- Jeffrey J Sisler
- CancerCare Manitoba, 675 McDermot Ave, Room ON2076, Winnipeg, MB R3E 0V9, Canada.
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Sivananthan G, Daly K, Halin N. Abstract No. 454: Efficacy and safety of radiofrequency wire recanalization of central venous occlusions. J Vasc Interv Radiol 2012. [DOI: 10.1016/j.jvir.2012.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Cheung WY, Butler JR, Kliewer EV, Demers AA, Musto G, Welch S, Sivananthan G, Navaratnam S. Analysis of wait times and costs during the peri-diagnostic period for non-small cell lung cancer. Lung Cancer 2010; 72:125-31. [PMID: 20822826 DOI: 10.1016/j.lungcan.2010.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 07/28/2010] [Accepted: 08/01/2010] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the wait times and healthcare costs around the time of non-small cell lung cancer (NSCLC) diagnosis for a large, population-based cohort of patients. METHODS Data on baseline demographics, diagnostic and staging tests, timelines of investigations, and frequency of physician visits and hospital admissions were obtained from a provincial cancer registry and health administrative databases for 2852 patients, who were diagnosed with NSCLC from 1996 to 2000 in Manitoba, Canada. Dates between investigations were used to determine wait times surrounding diagnosis and fee codes for physician and hospital services were used to estimate costs. RESULTS The median wait times from chest x-ray to chest computed tomography (CT) scan and from CT scan to definitive histological diagnosis were 8 (inter-quartile range 1-25) and 18 (inter-quartile range 3-42) days, respectively. At least 25% of patients waited more than 55 days from initial suspicion on chest x-ray to final diagnosis of NSCLC. The mean cost per case of NSCLC diagnosis was $6,978 (in Canadian dollars) where the majority of expenses was attributed to hospital admissions and repeated physician visits before a diagnosis was confirmed. CONCLUSIONS Despite clinical suspicion for NSCLC, a significant number of patients wait more than 8 weeks for a definitive diagnosis. Substantial costs are incurred by the Canadian universal healthcare system in the months surrounding diagnosis. Establishment of more efficient and cost-effective healthcare delivery in the peri-diagnostic time period may benefit the system as well as the patients.
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Affiliation(s)
- Winson Y Cheung
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, Canada
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