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Chen CJ, Ding D, Lee CC, Kearns KN, Pomeraniec IJ, Cifarelli CP, Arsanious DE, Liscak R, Hanuska J, Williams BJ, Yusuf MB, Woo SY, Ironside N, Warnick RE, Trifiletti DM, Mathieu D, Mureb M, Benjamin C, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Mackley HB, Zammar S, Patel NT, Padmanaban V, Beatson N, Saylany A, Lee J, Sheehan JP. Stereotactic Radiosurgery With Versus Without Embolization for Brain Arteriovenous Malformations. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa418_s087] [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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Zaorsky NG, Khunsriraksakul C, Acri SL, Liu DJ, Ba DM, Lin JL, Liu G, Segel JE, Drabick JJ, Mackley HB, Leslie DL. Medical Service Use and Charges for Cancer Care in 2018 for Privately Insured Patients Younger Than 65 Years in the US. JAMA Netw Open 2021; 4:e2127784. [PMID: 34613403 PMCID: PMC8495533 DOI: 10.1001/jamanetworkopen.2021.27784] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Currently, there are limited published data regarding resource use and spending on cancer care in the US. OBJECTIVE To characterize the most frequent medical services provided and the associated spending for privately insured patients with cancer in the US. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the MarketScan database for the calendar year 2018 from a sample of 27.1 million privately insured individuals, including patients with a diagnosis of the 15 most prevalent cancers, predominantly from large insurers and self-insured employers. Overall societal health care spending was estimated for each cancer type by multiplying the mean total spending per patient (estimated from MarketScan) by the number of privately insured patients living with that cancer in 2018, as reported by the National Cancer Institute's Surveillance, Epidemiology, and End Results program. Analyses were performed from February 1, 2018, to July 8, 2021. EXPOSURES Evaluation and management as prescribed by treating care team. MAIN OUTCOMES AND MEASURES Current Procedural Terminology and Healthcare Common Procedure Coding System codes based on cancer diagnosis code. RESULTS The estimated cost of cancer care in 2018 for 402 115 patients with the 15 most prevalent cancer types was approximately $156.2 billion for privately insured adults younger than 65 years in the US. There were a total of 38.4 million documented procedure codes for 15 cancers in the MarketScan database, totaling $10.8 billion. Patients with breast cancer contributed the greatest total number of services (10.9 million [28.4%]), followed by those with colorectal cancer (3.9 million [10.2%]) and prostate cancer (3.6 million [9.4%]). Pathology and laboratory tests contributed the highest number of services performed (11.7 million [30.5%]), followed by medical services (6.3 million [16.4%]) and medical supplies and nonphysician services (6.1 million [15.9%]). The costliest cancers were those of the breast ($3.4 billion [31.5%]), followed by lung ($1.1 billion [10.2%]) and colorectum ($1.1 billion [10.2%]). Medical supplies and nonphysician services contributed the highest total spent ($4.0 billion [37.0%]), followed by radiology ($2.1 billion [19.4%]) and surgery ($1.8 billion [16.7%]). CONCLUSIONS AND RELEVANCE This analysis suggests that patients with breast, colorectal, and prostate cancers had the greatest number of services performed, particularly for pathology and laboratory tests, whereas patients with breast, lung, lymphoma, and colorectal cancer incurred the greatest costs, particularly for medical supplies and nonphysician services. The cost of cancer care in 2018 for the 15 most prevalent cancer types was estimated to be approximately $156.2 billion for privately insured adults younger than 65 years in the US.
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Affiliation(s)
- Nicholas G. Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | | | - Samantha L. Acri
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Dajiang J. Liu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Djibril M. Ba
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - John L. Lin
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Guodong Liu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Joel E. Segel
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Health Policy and Administration, Pennsylvania State University, University Park
- Penn State Cancer Institute, Hershey, Pennsylvania
| | - Joseph J. Drabick
- Department of Medical Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Heath B. Mackley
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
- Department of Radiation Oncology, Geisinger Health System, Danville, Pennsylvania
| | - Douglas L. Leslie
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
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Tchelebi LT, Zaorsky NG, Rosenberg JC, Sharma NK, Tuanquin LC, Mackley HB, Ellis RJ. Reducing the Toxicity of Radiotherapy for Pancreatic Cancer With Magnetic Resonance-guided Radiotherapy. Toxicol Sci 2021; 175:19-23. [PMID: 32053201 DOI: 10.1093/toxsci/kfaa021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Pancreatic cancer is a highly fatal malignancy for which surgery is currently considered to be the only curative treatment. However, less than a quarter of patients have disease amenable to definitive surgical resection. Local treatment with radiation therapy is a promising alternative to surgery for those patients with unresectable disease. However, conventional radiation techniques with computed tomography (CT)-guided therapy have yielded disappointing results due to the inability to deliver ablative doses of ionizing radiation, while sparing the radiosensitive adjacent organs at risk. Magnetic resonance-guided radiotherapy (MRgRT) has emerged as an alternative to CT-guided radiation treatment which allows for the delivery of higher doses of radiation with low toxicity to surrounding structures. Further study into the use of MRgRT and dose escalation for locally advanced unresectable pancreatic cancer is needed.
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Affiliation(s)
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute.,Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania 17033
| | | | - Navesh K Sharma
- Department of Radiation Oncology, Penn State Cancer Institute
| | | | - Heath B Mackley
- Department of Radiation Oncology, Penn State Cancer Institute
| | - Rodney J Ellis
- Department of Radiation Oncology, Penn State Cancer Institute
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Spengler M, Wheelden M, Mackley HB, Drabick JJ. Durable Major Response With Pazopanib in Recurrent, Heavily Pretreated Metastatic Esthesioneuroblastoma Harboring a Fumarate Hydratase Mutation. JCO Precis Oncol 2021; 5:PO.20.00486. [PMID: 34036225 PMCID: PMC8140788 DOI: 10.1200/po.20.00486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/04/2021] [Accepted: 03/04/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Marianne Spengler
- Department of Hematology/Oncology, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Megan Wheelden
- Department of Hematology/Oncology, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Heath B Mackley
- Department of Radiation Oncology, Geisinger Medical Center, Danville, PA
| | - Joseph J Drabick
- Department of Hematology/Oncology, Penn State Milton S. Hershey Medical Center, Hershey, PA
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Chen CJ, Ding D, Lee CC, Kearns KN, Pomeraniec IJ, Cifarelli CP, Arsanious DE, Liscak R, Hanuska J, Williams BJ, Yusuf MB, Woo SY, Ironside N, Warnick RE, Trifiletti DM, Mathieu D, Mureb M, Benjamin C, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Mackley HB, Zammar S, Patel NT, Padmanaban V, Beatson N, Saylany A, Lee J, Sheehan JP. Stereotactic Radiosurgery With Versus Without Embolization for Brain Arteriovenous Malformations. Neurosurgery 2021; 88:313-321. [PMID: 33017465 DOI: 10.1093/neuros/nyaa418] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 02/29/2020] [Accepted: 07/02/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Prior comparisons of brain arteriovenous malformations (AVMs) treated using stereotactic radiosurgery (SRS) with or without embolization were inherently flawed, due to differences in the pretreatment nidus volumes. OBJECTIVE To compare the outcomes of embolization and SRS, vs SRS alone for AVMs using pre-embolization malformation features. METHODS We retrospectively reviewed International Radiosurgery Research Foundation AVM databases from 1987 to 2018. Patients were categorized into the embolization and SRS (E + SRS) or SRS alone (SRS-only) cohorts. The 2 cohorts were matched in a 1:1 ratio using propensity scores. Primary outcome was defined as AVM obliteration. Secondary outcomes were post-SRS hemorrhage, all-cause mortality, radiologic and symptomatic radiation-induced changes (RIC), and cyst formation. RESULTS The matched cohorts each comprised 101 patients. Crude AVM obliteration rates were similar between the matched E + SRS vs SRS-only cohorts (48.5% vs 54.5%; odds ratio = 0.788, P = .399). Cumulative probabilities of obliteration at 3, 4, 5, and 6 yr were also similar between the E + SRS (33.0%, 46.4%, 56.2%, and 60.8%, respectively) and SRS-only (32.9%, 46.2%, 56.0%, and 60.6%, respectively) cohorts (subhazard ratio (SHR) = 1.005, P = .981). Cumulative probabilities of radiologic RIC at 3, 4, 5, and 6 yr were lower in the E + SRS (25.0%, 25.7%, 26.7%, and 26.7%, respectively) vs SRS-only (45.3%, 46.2%, 47.8%, and 47.8%, respectively) cohort (SHR = 0.478, P = .004). Symptomatic and asymptomatic embolization-related complication rates were 8.3% and 18.6%, respectively. Rates of post-SRS hemorrhage, all-cause mortality, symptomatic RIC, and cyst formation were similar between the matched cohorts. CONCLUSION This study refutes the prevalent notion that AVM embolization negatively affects the likelihood of obliteration after SRS.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kathryn N Kearns
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - I Jonathan Pomeraniec
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - David E Arsanious
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir Hanuska
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Brian J Williams
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Mehran B Yusuf
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky
| | - Shiao Y Woo
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Ronald E Warnick
- Department of Neurosurgery, The Jewish Hospital, Cincinnati, Ohio
| | | | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Canada
| | - Monica Mureb
- Department of Neurosurgery, New York University, New York, New York
| | | | | | - Caleb E Feliciano
- Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Kevin M Cockroft
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Scott Simon
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Heath B Mackley
- Department of Radiation Oncology, Pennsylvania State University, Hershey, Pennsylvania
| | - Samer Zammar
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Neel T Patel
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Nathan Beatson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anissa Saylany
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Chen CJ, Ding D, Lee CC, Kearns KN, Pomeraniec IJ, Cifarelli CP, Arsanious DE, Liscak R, Hanuska J, Williams BJ, Yusuf MB, Woo SY, Ironside N, Warnick RE, Trifiletti DM, Mathieu D, Mureb M, Benjamin C, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Mackley HB, Zammar SG, Patel NT, Padmanaban V, Beatson N, Saylany A, Lee J, Sheehan JP. Embolization of Brain Arteriovenous Malformations With Versus Without Onyx Before Stereotactic Radiosurgery. Neurosurgery 2021; 88:366-374. [PMID: 32860409 DOI: 10.1093/neuros/nyaa370] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 04/24/2020] [Accepted: 06/24/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Embolization of brain arteriovenous malformations (AVMs) using ethylene-vinyl alcohol copolymer (Onyx) embolization may influence the treatment effects of stereotactic radiosurgery (SRS) differently than other embolysates. OBJECTIVE To compare the outcomes of pre-SRS AVM embolization with vs without Onyx through a multicenter, retrospective matched cohort study. METHODS We retrospectively reviewed International Radiosurgery Research Foundation AVM databases from 1987 to 2018. Embolized AVMs treated with SRS were selected and categorized based on embolysate usage into Onyx embolization (OE + SRS) or non-Onyx embolization (NOE + SRS) cohorts. The 2 cohorts were matched in a 1:1 ratio using de novo AVM features for comparative analysis of outcomes. RESULTS The matched cohorts each comprised 45 patients. Crude AVM obliteration rates were similar between the matched OE + SRS vs NOE + SRS cohorts (47% vs 51%; odds ratio [OR] = 0.837, P = .673). Cumulative probabilities of obliteration were also similar between the OE + SRS vs NOE + SRS cohorts (subhazard ratio = 0.992, P = .980). Rates of post-SRS hemorrhage, all-cause mortality, radiation-induced changes, cyst formation, and embolization-associated complications were similar between the matched cohorts. Sensitivity analysis for AVMs in the OE + SRS cohort embolized with Onyx alone revealed a higher rate of asymptomatic embolization-associated complications in this subgroup compared to the NOE + SRS cohort (36% vs 15%; OR = 3.297, P = .034), but the symptomatic complication rates were similar. CONCLUSION Nidal embolization using Onyx does not appear to differentially impact the outcomes of AVM SRS compared with non-Onyx embolysates. The embolic agent selected for pre-SRS AVM embolization should reflect both the experience of the neurointerventionalist and target of endovascular intervention.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kathryn N Kearns
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - I Jonathan Pomeraniec
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - David E Arsanious
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir Hanuska
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Brian J Williams
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Mehran B Yusuf
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky
| | - Shiao Y Woo
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Ronald E Warnick
- Department of Neurosurgery, The Jewish Hospital, Cincinnati, Ohio
| | | | - David Mathieu
- Department of Neurosurgery, Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, Canada
| | - Monica Mureb
- Department of Neurosurgery, New York University, New York, New York
| | | | | | - Caleb E Feliciano
- Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Kevin M Cockroft
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Scott Simon
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Heath B Mackley
- Department of Radiation Oncology, Pennsylvania State University, Hershey, Pennsylvania
| | - Samer G Zammar
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Neel T Patel
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Nathan Beatson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anissa Saylany
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Zaki P, Zhu J, Mackley HB, Rosenberg JC. Pregnancy screening practices and treatment of pregnant patients among radiation oncologists: results of an international survey. Ecancermedicalscience 2021; 15:1169. [PMID: 33680083 PMCID: PMC7929765 DOI: 10.3332/ecancer.2021.1169] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Indexed: 11/19/2022] Open
Abstract
Background The human embryo or foetus is susceptible to harmful effects of radiation, which include growth delay, malformations, impaired cognitive function, cancer and foetal demise. The purpose of this study is to describe pregnancy screening practices in radiation oncology, so that potential health effects may be avoided and areas of prevention may be identified. Methods An electronic survey was delivered to 6,304 members of the American Society for Radiation Oncology. The survey subjects were radiation oncologists who are currently practicing in the world. Chi-square tests and a multiple logistic regression model were used to analyse the data. All tests were two-sided and the statistical significance level used was 0.05. This study (STUDY00009765) was approved by an Institutional Review Board. Results A total of 434 responses from practicing radiation oncologists were received. Of these respondents, 69.1% were practicing in the United States. Of all respondents, 19.8% reported treating paediatric patients and 93.6% reported treating premenopausal patients. Despite 84.8% of radiation oncologists saying they would ‘strongly agree’ or ‘agree’ that one should screen for pregnancy prior to radiation therapy, 29.7% of respondents reported their department has no screening policy and 7.1% of respondents reported they do not screen for pregnancy. Having a departmental policy was associated with screening for pregnancy (p-value = 0.0005). Of all respondents, 93 reported treating a known pregnant patient. Of these 93 respondents, 76 reported intentionally treating and 17 reported accidentally treating a pregnant patient. Respondents who did not screen at time of simulation were significantly more likely to treat a pregnant patient than those who screened at time of simulation (p-value = 0.0459). Conclusions Heterogeneity exists among practicing radiation oncologists regarding pregnancy screening. Institutional policies should be clear and consistent. All members of the radiation oncology team should make every effort to minimise unintended radiation exposure to the embryo or foetus.
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Affiliation(s)
- Peter Zaki
- Department of Radiation Oncology, Penn State Cancer Institute, 400 University Dr, Hershey, PA 17033, USA.,Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA.,https://orcid.org/0000-0002-7451-4712
| | - Junjia Zhu
- Department of Public Health Sciences, Penn State Cancer Institute, 400 University Dr, Hershey, PA 17033, USA
| | - Heath B Mackley
- Department of Radiation Oncology, Penn State Cancer Institute, 400 University Dr, Hershey, PA 17033, USA
| | - Jennifer C Rosenberg
- Department of Radiation Oncology, Penn State Cancer Institute, 400 University Dr, Hershey, PA 17033, USA
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Chen CJ, Ding D, Lee CC, Kearns KN, Pomeraniec IJ, Cifarelli CP, Arsanious DE, Liscak R, Hanuska J, Williams BJ, Yusuf MB, Woo SY, Ironside N, Burke RM, Warnick RE, Trifiletti DM, Mathieu D, Mureb M, Benjamin C, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Mackley HB, Zammar SG, Patel NT, Padmanaban V, Beatson N, Saylany A, Lee JYK, Sheehan JP. Stereotactic radiosurgery with versus without prior Onyx embolization for brain arteriovenous malformations. J Neurosurg 2020:1-9. [PMID: 33307527 DOI: 10.3171/2020.7.jns201731] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/10/2020] [Accepted: 07/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Investigations of the combined effects of neoadjuvant Onyx embolization and stereotactic radiosurgery (SRS) on brain arteriovenous malformations (AVMs) have not accounted for initial angioarchitectural features prior to neuroendovascular intervention. The aim of this retrospective, multicenter matched cohort study is to compare the outcomes of SRS with versus without upfront Onyx embolization for AVMs using de novo characteristics of the preembolized nidus. METHODS The International Radiosurgery Research Foundation AVM databases from 1987 to 2018 were retrospectively reviewed. Patients were categorized based on AVM treatment approach into Onyx embolization (OE) and SRS (OE+SRS) or SRS alone (SRS-only) cohorts and then propensity score matched in a 1:1 ratio. The primary outcome was AVM obliteration. Secondary outcomes were post-SRS hemorrhage, all-cause mortality, radiological and symptomatic radiation-induced changes (RICs), and cyst formation. Comparisons were analyzed using crude rates and cumulative probabilities adjusted for competing risk of death. RESULTS The matched OE+SRS and SRS-only cohorts each comprised 53 patients. Crude rates (37.7% vs 47.2% for the OE+SRS vs SRS-only cohorts, respectively; OR 0.679, p = 0.327) and cumulative probabilities at 3, 4, 5, and 6 years (33.7%, 44.1%, 57.5%, and 65.7% for the OE+SRS cohort vs 34.8%, 45.5%, 59.0%, and 67.1% for the SRS-only cohort, respectively; subhazard ratio 0.961, p = 0.896) of AVM obliteration were similar between the matched cohorts. The secondary outcomes of the matched cohorts were also similar. Asymptomatic and symptomatic embolization-related complication rates in the matched OE+SRS cohort were 18.9% and 9.4%, respectively. CONCLUSIONS Pre-SRS AVM embolization with Onyx does not appear to negatively influence outcomes after SRS. These analyses, based on de novo nidal characteristics, thereby refute previous studies that found detrimental effects of Onyx embolization on SRS-induced AVM obliteration. However, given the risks incurred by nidal embolization using Onyx, this neoadjuvant intervention should be used judiciously in multimodal treatment strategies involving SRS for appropriately selected large-volume or angioarchitecturally high-risk AVMs.
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Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Cheng-Chia Lee
- 3Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kathryn N Kearns
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - I Jonathan Pomeraniec
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - David E Arsanious
- 4Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- 5Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir Hanuska
- 5Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | | | - Shiao Y Woo
- 6Radiation Oncology, University of Louisville, Kentucky
| | - Natasha Ironside
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Rebecca M Burke
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Ronald E Warnick
- 7Department of Neurosurgery, The Jewish Hospital, Cincinnati, Ohio
| | | | - David Mathieu
- 9Department of Neurosurgery, University of Sherbrooke, Canada
| | - Monica Mureb
- 10Department of Neurosurgery, New York University, New York, New York
| | - Carolina Benjamin
- 10Department of Neurosurgery, New York University, New York, New York
| | | | - Caleb E Feliciano
- 11Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | | | | | - Heath B Mackley
- 13Radiation Oncology, Pennsylvania State University, Hershey, Pennsylvania; and
| | | | | | | | - Nathan Beatson
- 14Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anissa Saylany
- 14Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Y K Lee
- 14Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Sha CM, Lehrer EJ, Hwang C, Trifiletti DM, Mackley HB, Drabick JJ, Zaorsky NG. Toxicity in combination immune checkpoint inhibitor and radiation therapy: A systematic review and meta-analysis. Radiother Oncol 2020; 151:141-148. [PMID: 32717359 DOI: 10.1016/j.radonc.2020.07.035] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [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: 06/03/2020] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Immune checkpoint inhibitor with radiation therapy (ICI + RT) is under investigation for improved patient outcome, so we performed a systematic review/meta-analysis of toxicities for ICI + RT compared to immune checkpoint inhibitor (ICI) therapy alone. MATERIALS AND METHODS A PRISMA-compliant systematic review of studies in MEDLINE (PubMed) and in the National Comprehensive Cancer Network guidelines was conducted, with primary outcome grade 3 + toxicity. Criteria for ICI alone were: phase III/IV trials that compared immunotherapy to placebo, chemotherapy, or alternative immunotherapy; and for ICI + RT: prospective/retrospective studies with an arm treated with ICI + RT. Meta-analysis was performed by random effects models using the DerSimonian and Laird method. The I2 statistic and Cochran's Q test were used to assess heterogeneity, while funnel plots and Egger's test assessed publication bias. RESULTS This meta-analysis included 51 studies (n = 15,398), with 35 ICI alone (n = 13,956) and 16 ICI + RT studies (n = 1,442). Our models showed comparable grade 3-4 toxicities in ICI + RT (16.3%; 95% CI, 11.1-22.3%) and ICI alone (22.3%; 95% CI, 18.1-26.9%). Stratification by timing of radiation and irradiated site showed no significant differences, but anti-CTLA-4 therapy and melanoma showed increased toxicity. The grade 5 toxicities were 1.1% and 1.9% for ICI alone and ICI + RT respectively. There was significant heterogeneity, but not publication bias. CONCLUSIONS The random effects model showed comparable grade 3-4 toxicity in using ICI + RT compared to ICI alone in CNS melanoma metastases, NSCLC, and prostate cancer. ICI + RT is safe for future clinical trials in these cancers.
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Affiliation(s)
- Congzhou M Sha
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Clara Hwang
- Department of Internal Medicine, Division of Hematology/Oncology, Henry Ford Health System, Detroit, MI, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Heath B Mackley
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Joseph J Drabick
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA; Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.
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10
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Horn SR, Stoltzfus KC, Mackley HB, Lehrer EJ, Zhou S, Dandekar SC, Fox EJ, Rizk EB, Trifiletti DM, Rao PM, Zaorsky NG. Long-term causes of death among pediatric patients with cancer. Cancer 2020; 126:3102-3113. [PMID: 32298481 DOI: 10.1002/cncr.32885] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 01/31/2020] [Revised: 02/23/2020] [Accepted: 03/09/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND The objectives of this study were to characterize the risk of death (1) from the primary cancer vs competing cause of death; and (2) from various causes of death vs the general poplation. The relative risk of death after a pediatric cancer diagnosis versus the general population and the risk of death from a primary cancer diagnosis versus competing causes of death. METHODS This retrospective, population-based study used the Surveillance, Epidemiology, and End Results database (1980-2015) and included patients aged 0 to 19 years at the time of diagnosis. Observed deaths were calculated; the risk of death versus the general population was assessed with standardized mortality ratios (SMRs). Competing risk models for the cause of death were performed. RESULTS There were 58,356 patients who were diagnosed, and the mortality rate was 22.8%. To assess causes of death, 6996 patients who died during the study period were included (45,580 total person-years at risk): 5128 (73%) died of their primary cancer, and 1868 (27%) died of a competing cause. Among all patients, the rate of death from the index cancer was higher than the rate of death from another cause within the first 5 years after diagnosis. The risk of death from a nonprimary cancer began to supersede the rate of death from the primary cancer 10 years after diagnosis for patients with germ cell tumors, lymphomas, and sarcomas. SMRs for the primary cancer were highest within the first 5 years after diagnosis for all cancers (SMRs, 100-50,000; P < .0001). The risk of death from competing causes (heart disease, suicide, and sepsis) was elevated (SMR, >100; P < .001). The risk of dying of heart disease was high, especially for patients with astrocytomas (SMR, 47.84; 95% confidence interval [CI], 27.87-76.59) and neuroblastomas (SMR, 98.59; 95% CI, 47.28-181.32). The risk of dying of suicide was high in most patients, particularly for those with osteosarcomas (SMR, 111.40; 95% CI, 2.82-620.69), Hodgkin lymphomas (SMR, 62.35; 95% CI, 34.89-102.83), and gonadal germ cell tumors (SMR, 28.97; 95% CI, 12.51-57.09). CONCLUSIONS The cause of death for patients with gonadal germ cell tumors, lymphomas, and sarcomas is more commonly a secondary cancer or noncancerous cause than the primary disease; their risk of death from competing causes (heart disease, suicide, and sepsis) rises throughout life.
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Affiliation(s)
- Samantha R Horn
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Kelsey C Stoltzfus
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Heath B Mackley
- 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
| | - Shouhao Zhou
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Smita C Dandekar
- Department of Pediatrics, Division of Hematology/Oncology, Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Edward J Fox
- Department of Orthopaedics and Rehabilitation, Penn State Hershey College of Medicine, Hershey, Pennsylvania
| | - Elias B Rizk
- Department of Neurosurgery, Penn State Cancer Institute, Hershey, Pennsylvania
| | | | - Pooja M Rao
- Department of Pediatrics, Division of Hematology/Oncology, Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - 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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11
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Liu J, Xu C, Zhu J, Sivik J, Drabick JJ, Mackley HB. Identifying the Optimal Fractionation Schedules for Improved Response Rates and Survival in Patients with Metastatic Melanoma Treated with Ipilimumab and Radiotherapy. CCTR 2020. [DOI: 10.2174/2542584601666180326111906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective:
There is a growing body of evidence that combining ipilimumab with higher
doses of radiotherapy may improve the response rates and survival in patients with metastatic melanoma
compared to lower doses of radiotherapy. However, the dose cutoff at which improved outcomes
are more likely to occur has not been properly identified.
Methods:
We conducted a retrospective analysis of 100 patients treated with ipilimumab and radiotherapy
for metastatic melanoma at a single institution from May 2011 to January 2017. Demographic,
clinical, and treatment factors, including the biological equivalent dose (BED) with an α/β
of 7, were recorded. Endpoints of interest included infield and global complete response (CR) after
the completion of radiation and ipilimumab based on the RECIST criteria (v1.1) and 12-month
overall survival (OS).
Results:
The BED cutoffs at which improved outcomes are more likely to occur are 46.5 Gy for infield
CR, 50.9 Gy for global CR, and 46.5 Gy for 12 month OS. The least aggressive fractionation
schedules used in this patient population that have a BED above the threshold for all 3 outcomes include
40 Gy in 20 fractions, 30 Gy in 6 fractions, and 24 Gy in 3 fractions.
Conclusion:
This hypothesis-generating study suggests that patients who cannot receive ablative intent
radiotherapy may be more likely to benefit from concurrent radiotherapy with ipilimumab if
their fractionation schedule has a BED above 46.5 - 50.9 Gy. Prospective trials evaluating this question
should be considered.
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Affiliation(s)
- Jason Liu
- The Penn State College of Medicine, Hershey, PA, United States
| | - Cong Xu
- The Division of Biostatistics at the Penn State Cancer Institute, Hershey, PA, United States
| | - Junjia Zhu
- The Division of Biostatistics at the Penn State Cancer Institute, Hershey, PA, United States
| | - Jeffrey Sivik
- The Division of Pharmacology at the Penn State Cancer Institute, Hershey, PA, United States
| | - Joseph J. Drabick
- The Division of Hematology/Oncology at the Penn State Cancer Institute, Hershey, PA, United States
| | - Heath B. Mackley
- The Division of Radiation Oncology at the Penn State Cancer Institute, Hershey, PA, United States
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Abstract
We identify cancer patients at highest risk of fatal stroke. This is a population-based study using nationally representative data from the Surveillance, Epidemiology, and End Results program, 1992-2015. Among 7,529,481 cancer patients, 80,513 died of fatal stroke (with 262,461 person-years at risk); the rate of fatal stroke was 21.64 per 100,000-person years, and the standardized mortality ratio (SMR) of fatal stroke was 2.17 (95% CI, 2.15, 2.19). Patients with cancer of the prostate, breast, and colorectum contribute to the plurality of cancer patients dying of fatal stroke. Brain and gastrointestinal cancer patients had the highest SMRs (>2-5) through the follow up period. Among those diagnosed at <40 years of age, the plurality of strokes occurs in patients treated for brain tumors and lymphomas; if >40, from cancers of the prostate, breast, and colorectum. For almost all cancers survivors, the risk of stroke increases with time.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA.
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.
| | - Ying Zhang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Leila T Tchelebi
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Heath B Mackley
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State College of Medicine, Hershey, PA, USA
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13
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Poulose J, Wheelden M, Mackley HB, Schmeck C, Zhu J, Pameijer C, Neves RI, Schell T, Mallon C, Drabick JJ. Utility of concurrent immunoradiation for locally advanced and/or medically inoperable melanoma and Merkel cell carcinoma. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e21053] [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: 11/20/2022] Open
Abstract
e21053 Background: Melanoma and Merkel Cell Carcinoma (MCC) are aggressive cutaneous malignancies with poor responses to cytotoxic chemotherapy. The use of immune checkpoint inhibitors (ICI) has substantially improved outcomes in metastatic disease and in the neoadjuvant setting. Addition of concurrent radiation therapy (RT) can augment the response of ICI, however there are little data on this combined approach as a neoadjuvant or non-operative strategy. Methods: We retrospectively analyzed outcomes of patients who received RT combined with an ICI against PD1, PD-L1, CTLA-4, or dual targets as neoadjuvant or definitive non-operative management for non-polymetastatic disease at our center from 2012 to 2018. Results: This study analyzed 14 patients, 7 males and 7 females, with a median age of 75 years. There were 10 patients with melanoma and 4 patients with MCC. Among them, 9 patients had stage III disease and 5 patients had oligometastatic disease. Prior treatments included surgery (71%), radiation (21%), and immunotherapy (21%) comprising interferon alpha (1), intralesional BCG (1), and Nivolumab (1). The ICI used were Pembrolizumab (5), Nivolumab (2), Avelumab (2), Ipilumumab (4) and Ipilumumab + Nivolumab (1). Immune related adverse events were seen in 8 patients and included endocrine (5), skin (4), and gastrointestinal (2) toxicity, majority of which were grade 1. Both grade 3 dermatitis and colitis were seen in 2 patients, and 1 patient had grade 3 colitis. There was 1 patient with grade 1 radiation dermatitis. Following concurrent ICI + RT, 4 patients who did not achieve a complete response (CR) at the irradiated site underwent surgical resection with no postoperative complications. An objective response at the irradiated site was seen in 13 (93%) patients, and 12 (86%) patients achieved a CR outside the radiated field. At the time of last follow up, 10 patients remain alive, of which 8 patients are in sustained complete remission. Conclusions: Concurrent use of ICI + RT was a safe approach in patients with locally advanced or medically inoperable melanoma and MCC with potential for durable complete remissions in the majority. Prospective studies are warranted to further validate this approach.
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Affiliation(s)
| | | | - Heath B. Mackley
- Penn State Cancer Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | | | - Junjia Zhu
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Colette Pameijer
- Division of Surgical Oncology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | | | - Todd Schell
- Penn State Hershey Medical Center, Hershey, PA
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14
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Zaorsky NG, Lin J, Ba D, Segel JE, Mackley HB, Drabick J, Liu G, Leslie D. The cost of prostate cancer care to society and to patients in the United States. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
116 Background: Our objectives are to characterize prostate cancer patient resource consumption and cost (I) to society, in 1 calendar year; and (II) to the patient, 1 year after his diagnosis. Methods: The MarketScan database was used to summarize cost, including gross payment to provider for service, copayment, and deductibles. We identified the top 20 Current Procedural Terminology (CPT) codes to characterize which procedures drove costs for both objectives. For Objective I, diagnoses were identified in 1 calendar year (2014); codes and their costs for all patients were calculated. For Objective II, diagnoses were set at time = 0, and all CPT and International Classification of Diseases codes were characterized 1 year after diagnosis (2012-2013). Results: For objective I, there were 95,642 procedures totalling $38,696,423. The plurality of procedures were hospital consultations, level 2 (i.e. history + physical + straightforward decision-making; 17,103 performed, average $80 each, total $1,418,954) and level 3 (+ low complexity decision-making; 9,726 performed; average $127 each, total $1,232,928). The most costly procedure to society was a radical prostatectomy (8,883 performed, average $2,003 each, total $17,694,508) with accompanying anesthesia (7,960 performed, average $1262 each, total $10,048,653). For objective II (characterized in Table), the mean payment per month was $2,794, including mean gross cost $2,673, mean copayment $32, and mean deductible $46. Conclusions: The typical cost of therapy to a prostate cancer patient is $2,800/month after diagnosis, primarily from surgery (constituting the majority of cost to society) and subsequently from office visits (constituting the plurality of procedures). Societal measures to reduce cost should be aimed at the operating room and consultations.[Table: see text]
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Affiliation(s)
| | - John Lin
- Penn State College of Medicine, Hershey, PA
| | - Djibril Ba
- Penn State College of Medicine, Hershey, PA
| | | | - Heath B. Mackley
- Penn State Cancer Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
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15
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Yee NS, Lengerich EJ, Schmitz KH, Maranki JL, Gusani NJ, Tchelebi L, Mackley HB, Krok KL, Baker MJ, Boer CD, Yee JD. Frontiers in Gastrointestinal Oncology: Advances in Multi-Disciplinary Patient Care. Biomedicines 2018; 6:E64. [PMID: 29865163 PMCID: PMC6027458 DOI: 10.3390/biomedicines6020064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/09/2018] [Accepted: 05/11/2018] [Indexed: 01/19/2023] Open
Abstract
Cancers of the digestive system remain highly lethal; therefore, the care of patients with malignant diseases of the digestive tract requires the expertise of providers from multiple health disciplines. Progress has been made to advance the understanding of epidemiology and genetics, diagnostic and screening evaluation, treatment modalities, and supportive care for patients with gastrointestinal cancers. At the Multi-Disciplinary Patient Care in Gastrointestinal Oncology conference at the Hershey Country Club in Hershey, Pennsylvania on 29 September 2017, the faculty members of the Penn State Health Milton S. Hershey Medical Center presented a variety of topics that focused on this oncological specialty. In this continuing medical education-certified conference, updates on the population sciences including health disparities and resistance training were presented. Progress made in various diagnostic evaluation and screening procedures was outlined. New developments in therapeutic modalities in surgical, radiation, and medical oncology were discussed. Cancer genetic testing and counseling and the supportive roles of music and arts in health and cancer were demonstrated. In summary, this disease-focused medical conference highlighted the new frontiers in gastrointestinal oncology, and showcase the multi-disciplinary care provided at the Penn State Cancer Institute.
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Affiliation(s)
- Nelson S Yee
- Division of Hematology-Oncology, Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Experimental Therapeutics Program, Penn State Cancer Institute, The Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
| | - Eugene J Lengerich
- Population Sciences Program, Penn State Cancer Institute, Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
| | - Kathryn H Schmitz
- Population Sciences Program, Penn State Cancer Institute, Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
| | - Jennifer L Maranki
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Health Milton S. Hershey Medical Center, The Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
| | - Niraj J Gusani
- Division of General Surgery and Surgical Oncology, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, The Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
| | - Leila Tchelebi
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, The Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
| | - Heath B Mackley
- Department of Radiology, Medicine, and Pediatrics, Penn State Health Milton S. Hershey Medical Center, The Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
| | - Karen L Krok
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Health Milton S. Hershey Medical Center, The Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
| | - Maria J Baker
- Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State Cancer Institute, The Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
| | - Claire de Boer
- Center Stage Arts in Health, Penn State Health Milton S. Hershey Medical Center, Department of Humanities, The Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
| | - Julian D Yee
- College of Liberal Arts, The Pennsylvania State University, State College, PA 16801, USA.
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16
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Wheelden M, Haley J, Schell T, Kokolus KM, Hershock D, Mallon C, Mackley HB, Sivik JM, Drabick JJ. Persistent high levels of circulating effector memory T cells and anti-nuclear antibodies in metastatic melanoma patients who experience durable CRs to immunotherapy after the cessation of treatment. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e21576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Todd Schell
- Penn State Hershey Medical Center, Hershey, PA
| | - Kathleen M Kokolus
- Penn State University, Milton S Hershey Medical Center - Dept of Microbiology and Immunology, Hershey, PA
| | | | | | - Heath B. Mackley
- Penn State Cancer Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
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17
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Affiliation(s)
| | - John Lin
- Penn State College of Medicine, Hershey, PA
| | - Djibril Ba
- Penn State College of Medicine, Hershey, PA
| | | | | | - Heath B. Mackley
- Penn State Cancer Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
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18
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Rakszawski K, LeBlanc FR, Fox EJ, Mackley HB, Pameijer C, Drabick JJ. Retrospective analysis of patients with high-grade soft-tissue sarcoma treated with interdigitated neoadjuvant MAI chemotherapy and radiation. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e23539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kevin Rakszawski
- Penn State Cancer Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | | | - Edward J Fox
- Department of Orthopaedic Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Heath B. Mackley
- Penn State Cancer Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Colette Pameijer
- Division of Surgical Oncology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Joseph J. Drabick
- Penn State Cancer Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
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19
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Liu J, Goldenberg D, Almokadem S, Crist H, Mackley HB. Long-term recurrence-free survival after an unplanned reduction in radiotherapy for HPV-positive oropharyngeal SCC: Two cases and a review of the literature. Ear Nose Throat J 2018; 96:E23-E27. [PMID: 28719715 DOI: 10.1177/014556131709600705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There is currently no clear distinction between the treatment of HPV-positive and HPV-negative oropharyngeal squamous cell carcinoma (OPSCC). HPV-positive OPSCC has been demonstrated to be more radiosensitive than its HPV-negative counterpart. Despite this, patients with HPV-positive OPSCC continue to receive a full dose of radiation (70 Gy) outside clinical trials. However, this high dose comes with considerable morbidities, including severe mucositis, dysphagia, and xerostomia. We describe the cases of 2 patients with HPV-positive OPSCC who received two cycles of high-dose cisplatin at 100 mg/m2 on 3 separate days, along with concurrent radiotherapy at 50 Gy in 25 fractions for one and 46 Gy in 23 fractions for the other. During treatment, both patients experienced significant acute-phase toxicities-including grade 3 mucositis, grade 3 nausea, and grade 2 dermatitis-and their treatment regimen was stopped before its planned completion. Nevertheless, after a follow-up of 75 and 78 months, respectively, neither patient exhibited any evidence of disease. Late toxicities included grade 1 xerostomia, grade 1 pharyngeal-phase dysphagia, and grade 1 dysgeusia with some foods. We conclude that de-escalating the dose of radiation for HPV-positive patients by 30% and identifying which patients can safely be treated with this level of dose reduction warrants further study.
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Affiliation(s)
- Jason Liu
- Penn State College of Medicine, Hershey, PA, USA
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20
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Koller KM, Mackley HB, Liu J, Wagner H, Talamo G, Schell TD, Pameijer C, Neves RI, Anderson B, Kokolus KM, Mallon CA, Drabick JJ. Improved survival and complete response rates in patients with advanced melanoma treated with concurrent ipilimumab and radiotherapy versus ipilimumab alone. Cancer Biol Ther 2017; 18:36-42. [PMID: 27905824 PMCID: PMC5323007 DOI: 10.1080/15384047.2016.1264543] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 11/20/2016] [Indexed: 12/19/2022] Open
Abstract
There is a growing body of evidence supporting the synergistic roles of radiotherapy and immunotherapy in the treatment of malignancy. Published case studies of the abscopal effect have been reported with the use of ipilimumab and radiotherapy in metastatic melanoma, but evidence supporting the routine use of this combination of therapy is limited. We conducted a retrospective analysis to evaluate patients treated with ipilimumab for advanced melanoma at a single institution from May 2011 to June 2015. Patients were grouped into those who had received concurrent radiotherapy while on ipilimumab (Ipi-RT), and those who did not. We then evaluated the treatment response following completion of ipilimumab. A total of 101 patients received ipilimumab in the prespecified time frame. 70 received Ipi-RT and 31 received ipilimumab without concurrent radiotherapy. Median overall survival (OS) was significantly increased in the concurrent Ipi-RT arm at 19 months vs. 10 months for ipilimumab alone (p = 0.01). Median progression free survival (PFS) was marginally increased in the Ipi-RT group compare with the ipilimumab alone group (5 months vs. 3 months, p = 0.20). Rates of complete response (CR) were significantly increased in the Ipi-RT group vs. ipilimumab alone (25.7% vs. 6.5%; p = 0.04), and rates of overall response (OR) in the groups were 37.1% vs. 19.4% (p = 0.11). No increase in toxicities was observed in the Ipi-RT group compare with ipilimumab alone. Prospective trials are needed to further clarify the role of radiotherapy with ipilimumab, but these encouraging preliminary observations suggest that this combination can induce more durable responses to immunotherapy.
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Affiliation(s)
- Kristian M. Koller
- The Division of Hematology Oncology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Heath B. Mackley
- Division of Radiation Oncology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jason Liu
- The Penn State College of Medicine, Hershey, PA, USA
| | - Henry Wagner
- Division of Radiation Oncology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Giampaolo Talamo
- The Division of Hematology Oncology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Todd D. Schell
- Department of Microbiology and Immunology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Colette Pameijer
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Rogerio I. Neves
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Bryan Anderson
- Department of Dermatology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Kathleen M. Kokolus
- Department of Microbiology and Immunology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Carol A. Mallon
- The Division of Hematology Oncology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Joseph J. Drabick
- The Division of Hematology Oncology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Short PF, Moran JR, Yang TC, Camacho F, Gusani NJ, Mackley HB, Matthews SA, Anderson RT. Effects of Hospital Type and Distance on Lymph Node Assessment for Colon Cancer Among Metropolitan and Nonmetropolitan Patients in Appalachia. Med Care Res Rev 2016; 73:546-64. [PMID: 26613702 PMCID: PMC4884173 DOI: 10.1177/1077558715619052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 10/23/2015] [Indexed: 01/15/2023]
Abstract
We studied differences in access to large or accredited cancer programs as a possible explanation for geographic disparities in adherence to the national guideline on lymph node assessment for Stages I to III colon cancer. State cancer registries were linked with Medicare claims of patients diagnosed from 2006 to 2008 from Appalachian counties of four states. Metropolitan and nonmetropolitan patients differed on adherence, proximity to high-volume or accredited hospitals, and hospital type. We modeled effects of hospital type on adherence with ordinary least squares and instrumental variables (instrumenting for hospital type with relative distance). The evidence was strongest for improved adherence in high-volume hospitals for nonmetropolitan patients. We estimate that roughly 100 deaths might be prevented over 5 years among each year's incident cases if the nonmetropolitan disparity in hospital volume were eliminated nationally. We conclude that regionalization or targeting smaller hospitals would improve adherence in nonmetropolitan areas, but also argue for improving adherence generally.
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Affiliation(s)
- Pamela Farley Short
- Department of Health Policy and Administration, Penn State University, 504 Ford Building, University Park, PA 16802, Phone: 814-863-9756, FAX: 814-863-0846,
| | - John R. Moran
- Department of Health Policy and Administration, Penn State University, 504 Ford Building, University Park, PA 16802, Phone: 814-865-8893, FAX: 814-863-2905,
| | - Tse-Chuan Yang
- Department of Sociology, University of Albany, State University of New York, 315 Arts & Sciences Building, 1400 Washington Avenue, Albany, NY 12222, Phone: 518-442-4647,
| | - Fabian Camacho
- Public Health Sciences, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, P.O. Box 800334, Charlottesville, Virginia 22908, USA,
| | - Niraj J. Gusani
- Departments of Surgery & Public Health Sciences, College of Medicine, Penn State University, 500 University Drive, H070, P.O. Box 850, Hershey, PA 17033-0850, Phone: (717) 531-5965, Fax: (717) 531-3649,
| | - Heath B. Mackley
- Departments of Radiology, Medicine, and Pediatrics, College of Medicine, Penn State University, 500 University Drive, CH63, P.O. Box 850, Hershey, PA 17033-0850, Phone: (717) 531-1523, Fax: (717) 531-0446,
| | - Stephen A. Matthews
- Departments of Sociology, Anthropology & Demography, Penn State University, 211 Oswald Tower, University Park, PA 16802, Phone: 814-863-9721, FAX: 814-863-8342,
| | - Roger T. Anderson
- Department of Public Health Sciences and UVA Cancer Center, University of Virginia, PO Box 800334, Charlottesville, VA 22908-0717, (434) 982-2480,
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22
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Yin M, Mackley HB, Drabick JJ, Harvey HA. Primary female breast sarcoma: clinicopathological features, treatment and prognosis. Sci Rep 2016; 6:31497. [PMID: 27510467 PMCID: PMC4980597 DOI: 10.1038/srep31497] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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: 04/26/2016] [Accepted: 07/15/2016] [Indexed: 11/23/2022] Open
Abstract
Primary breast sarcoma (PBS) is a rare and heterogeneous group of malignancies with limited publications. We obtained data from the Surveillance, Epidemiology, and End Results Program and performed analysis to determine clinicopathological characteristics of PBS and estimate their associations with overall survival (OS) and cancer-specific survival (CSS). Median age of PBS was 55–59 years and median OS was 108 months. Age, overlap or entire breast involvement, tumor histology, and tumor spread were associated with poor survival outcomes. In the multivariable analysis, tumor size, lymph node involvement, distant metastasis and histologic grade were correlated with survival outcomes (P < 0.001). In M0 patients, mastectomy was associated with worse survival outcomes compared with breast conservative surgery (BCS) (adjusted hazard ratio [adjHR], 1.80; 95% CI, 1.31–2.47), regardless of tumor size, tumor grade, tumor histology or radiation history. Adjuvant radiation improved survival outcomes in patients with tumor size >5 cm (adjHR, 0.63; 95% CI, 0.43–0.91), but not in patients with tumor size ≤ 5 cm. Our study demonstrated clinicopathological characteristics of PBS in the US population and supports performing BCS if R0 resection can be achieved, with radiation if tumor size is over 5 cm.
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Affiliation(s)
- Ming Yin
- Division of Hematology and Oncology, Penn State Hershey Cancer Institute, Hershey, USA
| | - Heath B Mackley
- Division of Radiation Oncology, Penn State Hershey Cancer Institute, Hershey, USA
| | - Joseph J Drabick
- Division of Hematology and Oncology, Penn State Hershey Cancer Institute, Hershey, USA
| | - Harold A Harvey
- Division of Hematology and Oncology, Penn State Hershey Cancer Institute, Hershey, USA
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23
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Koller KM, Mackley HB, Wagner H, Talamo G, Schell T, Pameijer C, Neves RI, Anderson B, Kokolus KM, Mallon C, Drabick JJ. Overall survival in patients with metastatic melanoma treated with concurrent ipilimumab and radiotherapy. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.3023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Henry Wagner
- Pennsylvania State Hershey Medical Center/Pennsylvania State Hershey Cancer Institute, Hershey, PA
| | | | - Todd Schell
- Penn State Milton S. Hershey Medical Center, Hershey, PA
| | | | | | | | - Kathleen M Kokolus
- Penn State University, Milton S Hershey Medical Center - Dept of Microbiology and Immunology, Hershey, PA
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24
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Yin M, Mackley HB, Drabick JJ, Harvey HA. Primary female breast sarcoma: Clinicopathological features, treatment and prognosis. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.11031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ming Yin
- Penn State Hershey Medical Center, Hershey, PA
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25
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Al-Marrawi MY, Mackley HB, Ali S, Wagner H, Joshi M, Holder S, Kaag M, Mallon C, Talamo G, Drabick JJ. Consolidation With Radiation or Concurrent Chemo-Radiation After Chemotherapy Results in Durable Complete Remissions of Isolated Nodal Recurrences of Urothelial Cancer: A Case Series and Review. Clin Genitourin Cancer 2016; 14:e393-9. [PMID: 26877063 DOI: 10.1016/j.clgc.2016.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/13/2016] [Accepted: 01/16/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Mhd Yaser Al-Marrawi
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA.
| | - Heath B Mackley
- Division of Radiation Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Suhail Ali
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Henry Wagner
- Division of Radiation Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Monika Joshi
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Sheldon Holder
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Mathew Kaag
- Division of Urological Surgery, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Carol Mallon
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Giampaolo Talamo
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Joseph J Drabick
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
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26
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Baker MJ, Goldstein AM, Gordon PL, Harbaugh KS, Mackley HB, Glantz MJ, Drabick JJ. An interstitial deletion within 9p21.3 and extending beyond CDKN2A predisposes to melanoma, neural system tumours and possible haematological malignancies. J Med Genet 2016; 53:721-727. [PMID: 26794401 DOI: 10.1136/jmedgenet-2015-103446] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [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: 08/06/2015] [Revised: 11/25/2015] [Accepted: 12/22/2015] [Indexed: 11/04/2022]
Abstract
Familial atypical multiple mole melanoma syndrome (FAMMM) is characterised by dysplastic naevi, malignant melanoma and pancreatic cancer. Given that large deletions involving CDKN2A (cyclin-dependent kinase inhibitor 2A) account for only 2% of cases, we describe a family that highlights the co-occurrence of both melanoma and neural system tumours to aid clinical recognition and propose a management strategy. A patient with multiple neurofibromas was referred with a provisional diagnosis of neurofibromatosis type 1 (NF1). Prior molecular testing, though, had failed to identify an NF1 mutation by sequencing and multiplex ligation-dependent probe amplification. His family history was significant for multiple in situ/malignant melanomas at young ages and several different cancers reminiscent of an underlying syndrome. A search of the Familial Cancer Database, FaCD Online, highlighted several families with cutaneous melanoma and nervous system tumours who were subsequently identified to have large deletions spanning CDKN2A Although sequencing of CDKN2A and TP53 failed to identify a mutation, a heterozygous CDKN2A deletion was identified by targeted array comparative genomic hybridisation (CGH). Whole-genome oligonucleotide array CGH and SNP analysis identified an interstitial deletion of at least 1.5 Mb within 9p21.3 and spanning approximately 25 genes. Identification of the underlying molecular abnormality permits predictive testing for at-risk relatives. Given the young cancer diagnoses, a surveillance regimen was developed and a clinical team organised for ongoing management so that genetic testing could be offered to both adults and minor children. Surveillance recommendations addressed cancer risks associated with FAMMM, and other cancers exhibited by this family with a large contiguous gene deletion.
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Affiliation(s)
- Maria J Baker
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Penn State Hershey Cancer Institute, Hershey, Pennsylvania, USA
| | - Alisa M Goldstein
- Division of Cancer Epidemiology and Genetics, Genetic Epidemiology Branch, National Cancer Institute, Bethesda, Maryland, USA
| | - Patricia L Gordon
- Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State Hershey Cancer Institute, Hershey, Pennsylvania, USA
| | - Kimberly S Harbaugh
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Penn State Hershey Cancer Institute, Hershey, Pennsylvania, USA
| | - Heath B Mackley
- Department of Radiation Oncology, Penn State Milton S. Hershey Medical Center, Penn State Hershey Cancer Institute, Hershey, Pennsylvania, USA
| | - Michael J Glantz
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Penn State Hershey Cancer Institute, Hershey, Pennsylvania, USA
| | - Joseph J Drabick
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Penn State Hershey Cancer Institute, Hershey, Pennsylvania, USA
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27
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Fleming ST, Mackley HB, Camacho F, Yao N, Gusani NJ, Seiber EE, Matthews SA, Yang TC, Hwang W. Patterns of Care for Metastatic Colorectal Cancer in Appalachia, and the Clinical, Sociodemographic, and Service Provider Determinants. J Rural Health 2015; 32:113-24. [PMID: 26241785 DOI: 10.1111/jrh.12132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Appalachia has high colorectal cancer (CRC) incidence and mortality, at least in part due to screening disparities. This paper examines patterns and determinants of metastatic colorectal cancer care. METHODS CRC patients diagnosed in 2006-2008 from 4 cancer registries (Kentucky, Ohio, Pennsylvania, and North Carolina) were linked to Medicare claims (2005-2009.) The final sample after exclusions included 855 stage IV and 590 stages I-III patients with metachronous or synchronous metastases. We estimate bivariate and multivariate analyses for several surgical and chemotherapeutic strategies of care using clinical, sociodemographic, and contextual determinants. RESULTS Among 1,445 CRC patients, 84% had primary tumor resection and 44% received chemotherapy. Of the chemotherapy patients, 44% received newer systemic agents for at least 75% of the cycles. One year survivors with liver or lung metastases were more likely to have their primary tumor resected immediately (86.1% vs 69.5% for liver, and 78.2% vs 64.9% for lung) and have their metastases resected/ablated (15.7% vs 2.6% for liver and 15.0% vs 0.5% for lung). Patients with stages I-III primary tumors (versus IV) were much more likely to be resected, but they were less likely to receive chemotherapy. Patients with comorbidities (congestive heart failure, dementia, or respiratory disease) had lower odds of chemotherapy. Smaller hospital size and surgical volume had higher odds of immediate versus delayed surgery. The newer chemotherapeutic agents were more common with higher surgical volume. CONCLUSIONS Metastatic colorectal cancer has clinical, sociodemographic, and service provider determinants.
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Affiliation(s)
- Steven T Fleming
- College of Public Health, University of Kentucky, Lexington, Kentucky
| | - Heath B Mackley
- College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Fabian Camacho
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Nengliang Yao
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Niraj J Gusani
- College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Eric E Seiber
- College of Public Health, Ohio State University, Columbus, Ohio
| | - Stephen A Matthews
- Department of Sociology, The Pennsylvania State University, University Park, Pennsylvania
| | - Tse-Chuan Yang
- Department of Sociology, University at Albany, SUNY, Albany, New York
| | - Wenke Hwang
- College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
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28
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Hess CB, Singer M, Khaku A, Malinou J, Juliano JJ, Varlotto JM, Wagner H, Liao J, Myers KR, Levine MP, Mackley HB. Optimal Frequency of Psychosocial Distress Screening in Radiation Oncology. J Oncol Pract 2015; 11:298-302. [DOI: 10.1200/jop.2014.003392] [Citation(s) in RCA: 10] [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] [Indexed: 11/20/2022] Open
Abstract
Thirty-seven percent of radiation oncology patients reported distress at least once during treatment. Screening at every-other-week intervals optimized efficiency and frequency, identifying nearly 90 distressed patients with 12 screening events.
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Affiliation(s)
- Clayton B. Hess
- Penn State Hershey College of Medicine; Penn State Hershey Cancer Institute; The Drs Kienle Center for Humanistic Medicine, Penn State Hershey College of Medicine, Hershey, PA; University of California Davis Comprehensive Cancer Center, Sacramento, CA; University of Texas Southwestern-Austin Transitional Residency Program, Austin, TX; and University of Massachusetts Medical School, Worcester, MA
| | - Maria Singer
- Penn State Hershey College of Medicine; Penn State Hershey Cancer Institute; The Drs Kienle Center for Humanistic Medicine, Penn State Hershey College of Medicine, Hershey, PA; University of California Davis Comprehensive Cancer Center, Sacramento, CA; University of Texas Southwestern-Austin Transitional Residency Program, Austin, TX; and University of Massachusetts Medical School, Worcester, MA
| | - Aliasgher Khaku
- Penn State Hershey College of Medicine; Penn State Hershey Cancer Institute; The Drs Kienle Center for Humanistic Medicine, Penn State Hershey College of Medicine, Hershey, PA; University of California Davis Comprehensive Cancer Center, Sacramento, CA; University of Texas Southwestern-Austin Transitional Residency Program, Austin, TX; and University of Massachusetts Medical School, Worcester, MA
| | - Justin Malinou
- Penn State Hershey College of Medicine; Penn State Hershey Cancer Institute; The Drs Kienle Center for Humanistic Medicine, Penn State Hershey College of Medicine, Hershey, PA; University of California Davis Comprehensive Cancer Center, Sacramento, CA; University of Texas Southwestern-Austin Transitional Residency Program, Austin, TX; and University of Massachusetts Medical School, Worcester, MA
| | - Justin J. Juliano
- Penn State Hershey College of Medicine; Penn State Hershey Cancer Institute; The Drs Kienle Center for Humanistic Medicine, Penn State Hershey College of Medicine, Hershey, PA; University of California Davis Comprehensive Cancer Center, Sacramento, CA; University of Texas Southwestern-Austin Transitional Residency Program, Austin, TX; and University of Massachusetts Medical School, Worcester, MA
| | - John M. Varlotto
- Penn State Hershey College of Medicine; Penn State Hershey Cancer Institute; The Drs Kienle Center for Humanistic Medicine, Penn State Hershey College of Medicine, Hershey, PA; University of California Davis Comprehensive Cancer Center, Sacramento, CA; University of Texas Southwestern-Austin Transitional Residency Program, Austin, TX; and University of Massachusetts Medical School, Worcester, MA
| | - Henry Wagner
- Penn State Hershey College of Medicine; Penn State Hershey Cancer Institute; The Drs Kienle Center for Humanistic Medicine, Penn State Hershey College of Medicine, Hershey, PA; University of California Davis Comprehensive Cancer Center, Sacramento, CA; University of Texas Southwestern-Austin Transitional Residency Program, Austin, TX; and University of Massachusetts Medical School, Worcester, MA
| | - Jason Liao
- Penn State Hershey College of Medicine; Penn State Hershey Cancer Institute; The Drs Kienle Center for Humanistic Medicine, Penn State Hershey College of Medicine, Hershey, PA; University of California Davis Comprehensive Cancer Center, Sacramento, CA; University of Texas Southwestern-Austin Transitional Residency Program, Austin, TX; and University of Massachusetts Medical School, Worcester, MA
| | - Kimberly R. Myers
- Penn State Hershey College of Medicine; Penn State Hershey Cancer Institute; The Drs Kienle Center for Humanistic Medicine, Penn State Hershey College of Medicine, Hershey, PA; University of California Davis Comprehensive Cancer Center, Sacramento, CA; University of Texas Southwestern-Austin Transitional Residency Program, Austin, TX; and University of Massachusetts Medical School, Worcester, MA
| | - Martha P. Levine
- Penn State Hershey College of Medicine; Penn State Hershey Cancer Institute; The Drs Kienle Center for Humanistic Medicine, Penn State Hershey College of Medicine, Hershey, PA; University of California Davis Comprehensive Cancer Center, Sacramento, CA; University of Texas Southwestern-Austin Transitional Residency Program, Austin, TX; and University of Massachusetts Medical School, Worcester, MA
| | - Heath B. Mackley
- Penn State Hershey College of Medicine; Penn State Hershey Cancer Institute; The Drs Kienle Center for Humanistic Medicine, Penn State Hershey College of Medicine, Hershey, PA; University of California Davis Comprehensive Cancer Center, Sacramento, CA; University of Texas Southwestern-Austin Transitional Residency Program, Austin, TX; and University of Massachusetts Medical School, Worcester, MA
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29
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Koller KM, Mackley HB, Wagner H, Neves RI, Schell T, Anderson B, Pameijer C, Mallon C, Drabick JJ. Concurrent ipilimumab and radiotherapy in patients with metastatic melanoma: A retrospective analysis. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.e20048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Henry Wagner
- Pennsylvania State Hershey Med Ctr/Pennsylvania State Hershey Cancer Inst, Hershey, PA
| | | | - Todd Schell
- Penn State Milton S. Hershey Medical Center, Hershey, PA
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30
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Kimmick GG, Camacho F, Mackley HB, Kern T, Yao N, Matthews SA, Fleming S, Lipscomb J, Liao J, Hwang W, Anderson RT. Individual, Area, and Provider Characteristics Associated With Care Received for Stages I to III Breast Cancer in a Multistate Region of Appalachia. J Oncol Pract 2014; 11:e9-e18. [PMID: 25228530 DOI: 10.1200/jop.2014.001397] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We describe individual, area, and provider characteristics associated with care patterns for early-stage breast cancer in Appalachian counties of Kentucky, North Carolina, Ohio, and Pennsylvania. METHODS Cases of stages I to III breast cancer from 2006 to 2008 were linked to Medicare claims occurring within 1 year of diagnosis. Rates of guideline-concordant endocrine therapy (n = 1,429), chemotherapy (n = 1,480), and radiation therapy (RT) after breast-conserving surgery were studied; RT was studied in women age ≥ 70 years with stage I estrogen receptor (ER) -positive/progesterone receptor (PR) -positive cancer, for whom RT was optional (n = 1,108), and in all others, for whom RT was guideline concordant (n = 1,422). Univariable and multivariable analyses were performed. Independent variables included age, race, county-level economic status, state, surgeon graduation year and volume, comorbidity, diagnosis year, Medicaid/Medicare dual status, histology, tumor size, tumor sequence, positive lymph nodes, ER/PR status, stage, trastuzumab use, and surgery type. RESULTS Population mean age was 74 years; 97% were white. For endocrine therapy, chemotherapy, and RT, guideline concordance was 76%, 48%, and 83%, respectively. Where it was optional, 77% received RT. Guideline-concordant endocrine therapy was lower in North Carolina versus Pennsylvania (odds ratio [OR], 0.60; 95% CI, 0.41 to 0.88) and higher if surgeon graduated between 1984 and 1988 versus ≥ 1989 (OR, 1.58; 95% CI, 1.06 to 2.34). Guideline-concordant chemotherapy varied significantly by state, county-level economic status, and surgeon volume. In guideline-concordant RT, lower surgeon volume (v highest) predicted RT use (OR, 1.63; 95% CI, 1.61 to 2.36). In optional RT, North Carolina residence (v Pennsylvania; OR, 0.29; 95% CI, 0.17 to 0.48) and counties with higher economic status (OR, 0.61; 95% CI, 0.40 to 0.94) predicated RT omission. CONCLUSION Notable variation in care by geographic and surgical provider characteristics provides targets for further research in underserved areas.
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Affiliation(s)
- Gretchen G Kimmick
- Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
| | - Fabian Camacho
- Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
| | - Heath B Mackley
- Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
| | - Teresa Kern
- Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
| | - Nengliang Yao
- Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
| | - Stephen A Matthews
- Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
| | - Steven Fleming
- Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
| | - Joseph Lipscomb
- Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
| | - Jason Liao
- Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
| | - Wenke Hwang
- Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
| | - Roger T Anderson
- Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
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31
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Mackley HB, Teslova T, Camacho F, Short PF, Anderson RT. Does Rurality Influence Treatment Decisions in Early Stage Laryngeal Cancer? J Rural Health 2014; 30:406-11. [DOI: 10.1111/jrh.12069] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Heath B. Mackley
- Department of Radiation Oncology, Penn State Hershey Cancer Institute; Penn State College of Medicine; Hershey Pennsylvania
| | - Tatiana Teslova
- Department of Radiation Oncology, Penn State Hershey Cancer Institute; Penn State College of Medicine; Hershey Pennsylvania
| | - Fabian Camacho
- Department of Public Health Sciences; Penn State College of Medicine; Hershey Pennsylvania
| | - Pamela F. Short
- Department of Health Policy and Administration; Penn State University; University Park Pennsylvania
| | - Roger T. Anderson
- Department of Public Health Sciences; Penn State College of Medicine; Hershey Pennsylvania
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32
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Varlotto JM, Decamp MM, Flickinger JC, Lake J, Recht A, Belani CP, Reed MF, Toth JW, Mackley HB, Sciamanna CN, Lipton A, Ali SM, Mahraj RPM, Gilbert CR, Yao N. Would screening for lung cancer benefit 75- to 84-year-old residents of the United States? Front Oncol 2014; 4:37. [PMID: 24639950 PMCID: PMC3945517 DOI: 10.3389/fonc.2014.00037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [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: 01/02/2014] [Accepted: 02/12/2014] [Indexed: 12/19/2022] Open
Abstract
Background: The National Lung Screening Trial demonstrated that screening for lung cancer improved overall survival (OS) and reduced lung cancer mortality in the 55- to 74-year-old age group by increasing the proportion of cancers detected at an early stage. Because of the increasing life expectancy of the American population, we investigated whether screening for lung cancer might benefit men and women aged 75–84 years. Materials/Methods: Rates of non-small cell lung cancer (NSCLC) from 2000 to 2009 were calculated in both younger and older age groups using the surveillance epidemiology and end reporting database. OS and lung cancer-specific survival (LCSS) in patients with Stage I NSCLC diagnosed from 2004 to 2009 were analyzed to determine the effects of age and treatment. Results: The per capita incidence of NSCLC decreased in the 55–74 cohort, but increased in the 75–84 cohort over the study period. Crude lung cancer death rates in the two age groups who had no specific treatment were 39.5 and 44.9%, respectively. These rates fell in both age groups when increasingly aggressive treatment was used. Rates of OS and LCSS improved significantly with increasingly aggressive treatment in the 75–84 age group. The survival benefits of increasingly aggressive treatment in 75- to 84-year-old females did not differ from their counterparts in the younger cohort. Conclusion: Screening for lung cancer might be of benefit to individuals at increased risk of lung cancer in the 75–84 age group. The survival benefits of aggressive therapy are similar in females between 55–74 and 75–84 years old.
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Affiliation(s)
- John M Varlotto
- Department of Radiation Oncology, University of Massachusetts Medical Center , Worcester, MA , USA
| | - Malcolm M Decamp
- Division of Thoracic Surgery, Department of Surgery, Northwestern Memorial Hospital , Chicago, IL , USA
| | - John C Flickinger
- Department of Radiation Oncology, Pittsburgh Cancer Institute , Pittsburgh, PA , USA
| | - Jessica Lake
- Pennsylvania State University College of Medicine , Hershey, PA , USA
| | - Abram Recht
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center , Boston, MA , USA
| | - Chandra P Belani
- Pennsylvania State University College of Medicine , Hershey, PA , USA ; Penn State Hershey Cancer Institute , Hershey, PA , USA
| | - Michael F Reed
- Pennsylvania State University College of Medicine , Hershey, PA , USA ; Heart and Vascular Institute, Penn State Hershey Medical Center , Hershey, PA , USA
| | - Jennifer W Toth
- Pennsylvania State University College of Medicine , Hershey, PA , USA ; Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Penn State Hershey Medical Center , Hershey, PA , USA
| | - Heath B Mackley
- Pennsylvania State University College of Medicine , Hershey, PA , USA ; Penn State Hershey Cancer Institute , Hershey, PA , USA
| | | | - Alan Lipton
- Pennsylvania State University College of Medicine , Hershey, PA , USA ; Penn State Hershey Cancer Institute , Hershey, PA , USA
| | - Suhail M Ali
- Pennsylvania State University College of Medicine , Hershey, PA , USA ; Penn State Hershey Cancer Institute , Hershey, PA , USA
| | | | - Christopher R Gilbert
- Pennsylvania State University College of Medicine , Hershey, PA , USA ; Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Penn State Hershey Medical Center , Hershey, PA , USA
| | - Nengliang Yao
- Department of Healthcare Policy and Research, Virginia Commonwealth University College of Medicine , Richmond, VA , USA
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Lynch MC, Drabick JJ, Neves RI, Fox EJ, Mackley HB, Anderson BE. Palliative effect of capecitabine and cetuximab for refractory metastatic squamous cell carcinoma of the perineum in epidermodysplasia verruciformis. Skinmed 2014; 12:54-56. [PMID: 24720087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A teenage girl presented with multiple warty skin lesions and had a diagnosis of epidermodysplasia verruciformis made several years later. Later in life she presented with an extensive SCC in situ in her gluteal crease that was surgically resected with wide margins. Despite this treatment, the lesion recurred with extension onto her lower back. Biopsies at the time confirmed SCC in situ of the perianal tissue and invasive SCC above her gluteal cleft.
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Kline CLB, Schiccitano A, Zhu J, Beachler C, Sheikh H, Harvey HA, Mackley HB, McKenna K, Staveley-O'Carroll K, Poritz L, Messaris E, Stewart D, Sivik J, El-Deiry WS. Personalized dosing via pharmacokinetic monitoring of 5-fluorouracil might reduce toxicity in early- or late-stage colorectal cancer patients treated with infusional 5-fluorouracil-based chemotherapy regimens. Clin Colorectal Cancer 2013; 13:119-26. [PMID: 24461492 DOI: 10.1016/j.clcc.2013.11.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 10/11/2013] [Accepted: 11/08/2013] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Therapeutic plasma 5-fluorouracil (5-FU) levels are achieved in only 20% to 30% of patients with the current practice of administering 5-FU doses based on body surface area (BSA). Alternatively, 5-FU doses can be adjusted based on 5-FU pharmacokinetic (PK) monitoring. Although benefits of PK monitoring of 5-FU in metastatic colorectal cancer (CRC) have been reported, its utility among patients with early stage disease has not been reported. PATIENTS AND METHODS We retrospectively examined the effect of 5-FU PK monitoring in 84 CRC patients (49 stage IV and 35 stage II/III) receiving mFOLFOX6 (modifiedFOLFOX6; modified 5-fluorouracil, leucovorin, oxaliplatin protocol) or mFOLFIRI (modified 5-fluorouracil, leucovorin, irinotecan protocol). Forty-six of the 84 patients received 5-FU doses based on BSA and 38 received doses that were adjusted with PK monitoring. 5-FU plasma levels were measured using a nanoparticle immunoassay method. RESULTS 5-fluorouracil PK monitoring significantly improved disease-free survival in stage II/III patients (P = .0429). There was also a trend towards improved progression-free survival among stage IV patients who had their 5-FU levels PK-monitored (P = .16). Moreover, 5-FU PK monitoring significantly reduced (P = .0437) and delayed (P = .0144) adverse effects in stage II/III patients. Toxicity occurred after the second 5-FU dose in the BSA group and after the sixth to seventh dose in the PK monitoring group. In stage IV patients, the onset of toxicities was also delayed with PK monitoring (P = .0605). CONCLUSION We provide evidence that PK monitoring of 5-FU is potentially beneficial for late stage and early stage CRC. These results contribute to the growing body of evidence regarding patient benefit when treatment decisions are based on the individual patient characteristics, in this case, a patients' 5-FU levels.
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Affiliation(s)
- Christina Leah B Kline
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Angelique Schiccitano
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Junjia Zhu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Cheryl Beachler
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Hassan Sheikh
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Harold A Harvey
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Heath B Mackley
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA; Division of Radiation Oncology, Department of Radiology, Penn State College of Medicine, Hershey, PA
| | - Kevin McKenna
- Department of Surgery, Penn State College of Medicine, Hershey, PA
| | | | - Lisa Poritz
- Department of Surgery, Penn State College of Medicine, Hershey, PA
| | | | - David Stewart
- Department of Surgery, Penn State College of Medicine, Hershey, PA
| | - Jeffrey Sivik
- Department of Pharmacology, Penn State College of Medicine, Hershey, PA
| | - Wafik S El-Deiry
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA.
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Anderson RT, Yang TC, Matthews SA, Camacho F, Kern T, Mackley HB, Kimmick G, Louis C, Lengerich E, Yao N. Breast cancer screening, area deprivation, and later-stage breast cancer in Appalachia: does geography matter? Health Serv Res 2013; 49:546-67. [PMID: 24117371 DOI: 10.1111/1475-6773.12108] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2013] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To model the relationship of an area-based measure of a breast cancer screening and geographic area deprivation on the incidence of later stage breast cancer (LSBC) across a diverse region of Appalachia. DATA SOURCE Central cancer registry data (2006-2008) from three Appalachian states were linked to Medicare claims and census data. STUDY DESIGN Exploratory spatial analysis preceded the statistical model based on negative binomial regression to model predictors and effect modification by geographic subregions. PRINCIPAL FINDINGS Exploratory spatial analysis revealed geographically varying effects of area deprivation and screening on LSBC. In the negative binomial regression model, predictors of LSBC included receipt of screening, area deprivation, supply of mammography centers, and female population aged>75 years. The most deprived counties had a 3.31 times greater rate of LSBC compared to the least deprived. Effect of screening on LSBC was significantly stronger in northern Appalachia than elsewhere in the study region, found mostly for high-population counties. CONCLUSIONS Breast cancer screening and area deprivation are strongly associated with disparity in LBSC in Appalachia. The presence of geographically varying predictors of later stage tumors in Appalachia suggests the importance of place-based health care access and risk.
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Affiliation(s)
- Roger T Anderson
- Department of Public Health Science, College of Medicine, The Pennsylvania State University, Hershey, PA
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Fleming ST, Mackley HB, Camacho F, Seiber EE, Gusani NJ, Matthews SA, Liao J, Yang TC, Hwang W, Yao N. Clinical, sociodemographic, and service provider determinants of guideline concordant colorectal cancer care for Appalachian residents. J Rural Health 2013; 30:27-39. [PMID: 24383482 DOI: 10.1111/jrh.12033] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Colorectal cancer represents a significant cause of morbidity and mortality, particularly in Appalachia where high mortality from colorectal cancer is more prevalent. Adherence to treatment guidelines leads to improved survival. This paper examines determinants of guideline concordance for colorectal cancer. METHODS Colorectal cancer patients diagnosed in 2006-2008 from 4 cancer registries (Kentucky, Ohio, Pennsylvania, and North Carolina) were linked to Medicare claims (2005-2009). Final sample size after exclusions was 2,932 stage I-III colon, and 184 stage III rectal cancer patients. The 3 measures of guideline concordance include adjuvant chemotherapy (stage III colon cancer, <80 years), ≥12 lymph nodes assessed (resected stage I-III colon cancer), and radiation therapy (stage III rectal cancer, <80 years). Bivariate and multivariate analyses with clinical, sociodemographic, and service provider covariates were estimated for each of the measures. RESULTS Rates of chemotherapy, lymph node assessment, and radiation were 62.9%, 66.3%, and 56.0%, respectively. Older patients had lower rates of chemotherapy and radiation. Five comorbidities were significantly associated with lower concordance in the bivariate analyses: myocardial infarction, congestive heart failure, respiratory diseases, dementia with chemotherapy, and diabetes with adequate lymph node assessment. Patients treated by hospitals with no Commission on Cancer (COC) designation or lower surgical volumes had lower odds of adequate lymph node assessment. CONCLUSIONS Clinical, sociodemographic, and service provider characteristics are significant determinants of the variation in guideline concordance rates of 3 colorectal cancer measures.
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Affiliation(s)
- Steven T Fleming
- Departments of Epidemiology & Health Services Management, University of Kentucky College of Public Health, Lexington, Kentucky
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Kimmick GG, Camacho F, Kern T, Fleming S, Liao J, Matthews S, Hwang W, Mackley HB, Lipscomb J, Short P, Moran J, Yao N, Anderson RT. Predictors of care for early-stage breast cancer in Appalachia. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.6558] [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: 11/20/2022] Open
Abstract
6558 Background: We studied care for early-stage breast cancer in Appalachia, a region with health infrastructure, socioeconomic (SES) and geographic disparities. Methods: Cases of stage I-III breast cancer diagnosed 2006-2008 were identified from cancer registries of KY, NC, OH, and PA and linked to Medicare data. Guideline concordance was studied in eligible groups, as follows: endocrine therapy for hormone receptor positive cancer (n=1429); and radiation (RT) use after breast conserving surgery (BCS) divided into two groups - age 70 years and older with ER/PR+, <2 cm, node negative tumors where it may have been acceptable to forgo RT (OptRT, n=1108) and all other cases (IndRT, n=1422). Multivariate (MV) and univariate analyses were performed. Covariates included age, state, Appalachian Regional Commission (ARC) economic status, Commission of Cancer (CoC) status, state, access to care, number of beds, surgery facility ownership, volume, and chemotherapy/radiation offered, provider graduation year and volume, Charlson comorbidity, diagnosis year, Medicaid/Medicare dual status, histology, tumor size, tumor sequence, positive lymph nodes, ER/PR status, stage, herceptin use, and BCS/mastectomy indicator. Results: Mean age was 74 years and 97% were white. Guideline-concordance was 76% for endocrine therapy, 83% for IndRT, and 77% for OptRT. Younger age predicted higher concordance in all groups. Endocrine therapy use was lower in NC vs PA (OR 0.60; 95% CI 0.41-0.88) and greater for cases whose provider graduated in years 1984-1988, vs. 1989+ (1.55; 1.06-2.29). In IndRT, provider volume in the 3rdquartile vs. highest quartile predicted increased radiation use (2.36; 1.46-3.81). In OptRT, less receipt of radiation was predicted by residence in NC vs. PA (0.26; 0.18-0.48), and competitive ARC class vs. transitional (0.60; 0.36-0.99). Conclusions: Within Appalachia, there are SES and provider characteristics that are associated with use of guideline concordant care.
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Affiliation(s)
| | | | | | | | - Jason Liao
- Penn State Hershey Medical Center, Hershey, PA
| | | | | | | | | | | | - John Moran
- Penn State University, University Park, PA
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Yao N, Mackley HB, Anderson RT, Recht A. Survival after partial breast brachytherapy in elderly patients with nonmetastatic breast cancer. Brachytherapy 2013; 12:293-302. [PMID: 23477884 DOI: 10.1016/j.brachy.2013.01.168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 01/09/2013] [Accepted: 01/15/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Despite growing utilization of accelerated partial breast irradiation using brachytherapy (APBI-Brachy) for elderly breast cancer patients, there are limited data from randomized Phase III trials to support its routine use. This study uses population-based data to examine whether APBI-Brachy results in comparable survival rates compared with whole breast irradiation (WBI). METHODS A sample of 29,647 female patients diagnosed with nonmetastatic breast cancer in 2002-2007 treated with breast-conserving surgery and radiotherapy was identified in the Surveillance, Epidemiology, and End Results Program-Medicare data set. Log-rank tests, Cox proportional hazards models, instrumental variable analysis, and subgroup analysis were used to study the comparative effectiveness of APBI-Brachy and WBI. RESULTS During a median followup of 3.6 and 4.8 years, 123 (7.7%) and 3438 (13.6%) patients died after APBI-Brachy and WBI, respectively. Recurrence-free survival (p = 0.9711) and overall survival rates (p = 0.0551) did not differ significantly between the two radiation modalities. After accounting for tumor characteristics, patient characteristics, community factors, and comorbidities, the recurrence-free survival (hazard ratio, 1.05; 95% confidence interval, 0.90-1.23; p = 0.5125) and overall survival (hazard ratio, 0.87; 95% confidence interval, 0.72-1.04; p = 0.1332) rates were still not significantly different between patients treated with APBI-Brachy and WBI. CONCLUSION Partial breast brachytherapy and WBI resulted in similar recurrence-free and overall survival rates in this cohort of elderly breast cancer patients, even after adjustment for the more favorable characteristics of patients in the former group. These findings will need to be confirmed by the randomized trials comparing these modalities.
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Affiliation(s)
- Nengliang Yao
- Department of Health Policy and Administration, Pennsylvania State University, University Park, PA 16802, USA.
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Lake J, Flickinger JC, Varlotto JM, Recht A, DeCamp MM, Belani CP, Mackley HB, Sciamanna C, Reed M, Toth J, Lipton A, Ali SM. Would screening benefit 75- to 84-year-old patients with non-small cell lung cancer (NSCLC)? J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.7055] [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: 11/20/2022] Open
Abstract
7055 Background: The Lung Cancer Screening Trial has shown an overall survival (OS) benefit and reduced lung cancer mortality in the 55-74 age group (gp). We chose to evaluate whether NSCLC patients aged 75-84 are increasing in the USA and whether they would benefit from aggressive therapy. Methods: SEER-17 was used to calculate NSCLC rates during the years 2000-2008. SEER-9 was used to estimate the proportional change in both 55-74 and 75-84 gp from 1973-2008. OS was analyzed in a modern population from SEER-17 (2004-2008) to assess the effects of increasingly aggressive therapy (observation(Ob), radiation (RT) or lobectomy (LB)) for a proposed screening population with T1N0 tumors. Chi-square test and Cox Regression (CR) were used to evaluate OS. Paired T-tests assessed changes in rates and proportions over time. Results: The 55-74 gp rose from 64.4% in 1973 to 67.25% in 1984, but fell to 58.8% by 2008, while the 75-84 gp rose from 12.1% in 1973 to 24% in 2008 (p<0.01), similar in both sexes. The rates/100,000 have been increasing in the 75-84 gp (p=0.02), mainly in females (p=0.003) while the rates in the 55-74 gp did not vary, but fell for men (p=0.03). In the Ob gp (n=1344), NSCLC was the most common cause of death (COD) in the 55-74 (29.8%) and 75-84 gp (40.6%), more than all other CODs combined (median survival (MS) = 11mn). CR revealed that OS was associated with the 55-74 gp (0.59) and females (0.62) (p < 0.001). In the RT gp (n=1870), MS was 14mn and lung cancer was the most common COD at 27.7% (55-74) and 28.8% (75-84), again more than all other CODs combined. CR found that females (0.68) and black race (0.72) had better OS (p<0.017), but age was not. MS was 24 mn in the LB group (n=9384). COD from NSCLC and all other CODs was 8.2% and 6.1% (55-74) and 10.9% and 11.4% (75-84). CR showed that 55-74 (0.36), females (0.58), and Asians (0.73) had lower death rates (all p<0.015). Mean OS between the 55-74 (26.0) and 75-84 (24.2) gp showed a small yet significant difference. Conclusions: Rates and proportions of NSCLC have been steadily increasing in the 75-84 gp. These data show that COD by lung cancer decreased significantly with increasingly aggressive treatment and treatment reduced the effects of age gp on survival. We feel that screening may be of benefit to the 75-84 gp.
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Affiliation(s)
| | | | | | - Abram Recht
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Malcolm M. DeCamp
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | | | | | | | - Michael Reed
- Pennsylvania State University Cardiovascular Institute, Hershey, PA
| | | | - Allan Lipton
- Division of Oncology, Penn State Hershey Cancer Institute, Penn State Hershey Medical Center, Hershey, PA
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Sohrabi S, Drabick JJ, Crist H, Goldenberg D, Sheehan JM, Mackley HB. Neoadjuvant concurrent chemoradiation for advanced esthesioneuroblastoma: a case series and review of the literature. J Clin Oncol 2011; 29:e358-61. [PMID: 21282533 DOI: 10.1200/jco.2010.30.9278] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Mackley HB, Reddy CA, Lee SY, Harnisch GA, Mayberg MR, Hamrahian AH, Suh JH. Intensity-modulated radiotherapy for pituitary adenomas: The preliminary report of the Cleveland Clinic experience. Int J Radiat Oncol Biol Phys 2007; 67:232-9. [PMID: 17084541 DOI: 10.1016/j.ijrobp.2006.08.039] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Revised: 08/08/2006] [Accepted: 08/15/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE Intensity-modulated radiotherapy (IMRT) is being increasingly used for the treatment of pituitary adenomas. However, there have been few published data on the short- and long-term outcomes of this treatment. This is the initial report of the Cleveland Clinic's experience. METHODS AND MATERIALS Between February 1998 and December 2003, 34 patients with pituitary adenomas were treated with IMRT. A retrospective chart review was conducted for data analysis. RESULTS With a median follow-up of 42.5 months, the treatment has proven to be well tolerated, with performance status remaining stable in 90% of patients. Radiographic local control was 89%, and among patients with secretory tumors, 100% had a biochemical response. Only 1 patient required salvage surgery for progressive disease, giving a clinical progression free survival of 97%. The only patient who received more than 46 Gy experienced optic neuropathy 8 months after radiation. Smaller tumor volume significantly correlated with subjective improvements in nonvisual neurologic complaints (p = 0.03), and larger tumor volume significantly correlated with subjective worsening of visual symptoms (p = 0.05). New hormonal supplementation was required for 40% of patients. Younger patients were significantly more likely to require hormonal supplementation (p = 0.03). CONCLUSIONS Intensity-modulated radiation therapy is a safe and effective treatment for pituitary adenomas over the short term. Longer follow-up is necessary to determine if IMRT confers any advantage with respect to either tumor control or toxicity over conventional radiation modalities.
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Affiliation(s)
- Heath B Mackley
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA.
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Mackley HB, Videtic GMM. Primary carcinoid tumors of the lung: a role for radiotherapy. Oncology (Williston Park) 2006; 20:1537-43; discussion 1544-5, 1549. [PMID: 17153907] [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: 05/12/2023]
Abstract
Primary neuroendocrine neoplasms of the lung represent a clinical spectrum of tumors ranging from the relatively benign and slow-growing typical carcinoid to the highly aggressive small-cell lung carcinoma. The rarity of carcinoids has made the role of radiation therapy in their management controversial. This review considers the results of published studies to generate treatment recommendations and identify areas for future research. Surgery remains the standard of care for medically operable disease. Histology plays the most important role in determining the role of adjuvant radiation. Resected typical carcinoids likely do not require adjuvant therapy irrespective of nodal statius. Resected atypical carcinoids and large-cell neuroendocrine carcinomas have a significant risk of localfailure, for which adjuvant radiation likely improves local control. Definitive radiation is warranted in unresectable disease. Palliative radiation for symptomatic lesions has demonstrated efficacy for all histologies. Collaborative group trials are warranted.
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Affiliation(s)
- Heath B Mackley
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
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