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Wang YF, Price MJ, Elliston CD, Munbodh R, Spina CS, Horowitz DP, Kachnic LA. Enhancing Safety in AI-Driven Cone Beam CT-based Online Adaptive Radiation Therapy: Development and Implementation of an Interdisciplinary Workflow. Adv Radiat Oncol 2024; 9:101399. [PMID: 38292890 PMCID: PMC10823112 DOI: 10.1016/j.adro.2023.101399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/11/2023] [Indexed: 02/01/2024] Open
Abstract
Purpose The emerging online adaptive radiation therapy (OART) treatment strategy based on cone beam computed tomography allows for real-time replanning according to a patient's current anatomy. However, implementing this procedure requires a new approach across the patient's care path and monitoring of the "black box" adaptation process. This study identifies high-risk failure modes (FMs) associated with AI-driven OART and proposes an interdisciplinary workflow to mitigate potential medical errors from highly automated processes, enhance treatment efficiency, and reduce the burden on clinicians. Methods and Materials An interdisciplinary working group was formed to identify safety concerns in each process step using failure mode and effects analysis (FMEA). Based on the FMEA results, the team designed standardized procedures and safety checklists to prevent errors and ensure successful task completion. The Risk Priority Numbers (RPNs) for the top twenty FMs were calculated before and after implementing the proposed workflow to evaluate its effectiveness. Three hundred seventy-four adaptive sessions across 5 treatment sites were performed, and each session was evaluated for treatment safety and FMEA assessment. Results The OART workflow has 4 components, each with 4, 8, 13, and 4 sequentially executed tasks and safety checklists. Site-specific template preparation, which includes disease-specific physician directives and Intelligent Optimization Engine template testing, is one of the new procedures introduced. The interdisciplinary workflow significantly reduced the RPNs of the high-risk FMs, with an average decrease of 110 (maximum reduction of 305.5 and minimum reduction of 27.4). Conclusions This study underscores the importance of addressing high-risk FMs associated with AI-driven OART and emphasizes the significance of safety measures in its implementation. By proposing a structured interdisciplinary workflow and integrated checklists, the study provides valuable insights into ensuring the safe and efficient delivery of OART while facilitating its effective integration into clinical practice.
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Affiliation(s)
- Yi-Fang Wang
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Michael J. Price
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Carl D. Elliston
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Reshma Munbodh
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Catherine S. Spina
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - David P. Horowitz
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Lisa A. Kachnic
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
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Kinslow CJ, Kumar P, Olfson M, Wall MM, Petridis PD, Horowitz DP, Wang TJC, Kachnic LA, Cheng SK, Prigerson HG, Yu JB, Neugut AI. Prognosis and risk of suicide after cancer diagnosis. Cancer 2024; 130:588-596. [PMID: 38018695 DOI: 10.1002/cncr.35118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 09/13/2023] [Accepted: 10/20/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Suicide rates are elevated after cancer diagnosis. Existential distress caused by awareness of one's impending death is well-described in patients with cancer. The authors hypothesized that suicide risk is associated with cancer prognosis, and the impact of prognosis on suicide risk is greatest for populations with higher baseline suicide risk. METHODS The authors identified patients (≥16 years old) with newly diagnosed cancers from 2000 to 2019 in the Surveillance, Epidemiology, and End Results database, representing 27% of US cancers. Multiple primary-standardized mortality ratios (SMR) were used to estimate the relative risk of suicide within 6 months of diagnosis compared to the general US population, adjusted for age, sex, race, and year of follow-up. Suicide rates by 20 most common cancer sites were compared with respective 2-year overall survival rates (i.e., prognosis) using a weighted linear regression model. RESULTS Among 6,754,704 persons diagnosed with cancer, there were 1610 suicide deaths within 6 months of diagnosis, three times higher than the general population (SMR = 3.1; 95% confidence interval, 3.0-3.3). Suicide risk by cancer site was closely associated with overall prognosis (9.5%/percent survival deficit, R2 = 0.88, p < .0001). The association of prognosis with suicide risk became attenuated over time. For men, the risk of suicide increased by 2.8 suicide deaths per 100,000 person-years (p < .0001) versus 0.3 in women (p < .0001). The risk was also higher for persons ≥60 old and for the White (vs. Black) race. CONCLUSIONS Poorer prognosis was closely associated with suicide risk early after cancer diagnosis and had a greater effect on populations with higher baseline risks of suicide. This model highlights the need for enhanced psychiatric surveillance and continued research in this patient population.
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Affiliation(s)
- Connor J Kinslow
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Prashanth Kumar
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Mark Olfson
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York, USA
- The New York State Psychiatric Institute, Columbia University, New York, New York, USA
| | - Melanie M Wall
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York, USA
- The New York State Psychiatric Institute, Columbia University, New York, New York, USA
| | - Petros D Petridis
- Department of Psychiatry, NYU Langone Center for Psychedelic Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - David P Horowitz
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Tony J C Wang
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Simon K Cheng
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Holly G Prigerson
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, USA
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - James B Yu
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Alfred I Neugut
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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3
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Katz L, Horowitz DP, Kachnic LA. Acute and Chronic Complications After Treatment of Locoregional Anal Cancer: Prevention and Management Strategies. J Natl Compr Canc Netw 2023; 21:1204-1211. [PMID: 37935101 DOI: 10.6004/jnccn.2023.7042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/31/2023] [Indexed: 11/09/2023]
Abstract
Definitive chemoradiotherapy (CRT) for anal cancer spares patients the morbidity of a colostomy surgery and optimizes cancer outcomes. CRT, however, has introduced a unique acute and chronic toxicity profile, which has greatly improved over the years with the introduction of advanced radiotherapy techniques. This article provides the multidisciplinary care team with practical tools to mitigate and manage acute and chronic complications from definitive treatment of anal cancer.
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Affiliation(s)
- Leah Katz
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York
| | - David P Horowitz
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York
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Gondi V, Deshmukh S, Brown PD, Wefel JS, Armstrong TS, Tome WA, Gilbert MR, Konski A, Robinson CG, Bovi JA, Benzinger TLS, Roberge D, Kundapur V, Kaufman I, Shah S, Usuki KY, Baschnagel AM, Mehta MP, Kachnic LA. Sustained Preservation of Cognition and Prevention of Patient-Reported Symptoms With Hippocampal Avoidance During Whole-Brain Radiation Therapy for Brain Metastases: Final Results of NRG Oncology CC001. Int J Radiat Oncol Biol Phys 2023; 117:571-580. [PMID: 37150264 DOI: 10.1016/j.ijrobp.2023.04.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/18/2023] [Accepted: 04/29/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE Initial report of NRG Oncology CC001, a phase 3 trial of whole-brain radiation therapy plus memantine (WBRT + memantine) with or without hippocampal avoidance (HA), demonstrated neuroprotective effects of HA with a median follow-up of fewer than 8 months. Herein, we report the final results with complete cognition, patient-reported outcomes, and longer-term follow-up exceeding 1 year. METHODS AND MATERIALS Adult patients with brain metastases were randomized to HA-WBRT + memantine or WBRT + memantine. The primary endpoint was time to cognitive function failure, defined as decline using the reliable change index on the Hopkins Verbal Learning Test-Revised (HVLT-R), Controlled Oral Word Association, or the Trail Making Tests (TMT) A and B. Patient-reported symptom burden was assessed using the MD Anderson Symptom Inventory with Brain Tumor Module and EQ-5D-5L. RESULTS Between July 2015 and March 2018, 518 patients were randomized. The median follow-up for living patients was 12.1 months. The addition of HA to WBRT + memantine prevented cognitive failure (adjusted hazard ratio, 0.74, P = .016) and was associated with less deterioration in TMT-B at 4 months (P = .012) and HVLT-R recognition at 4 (P = .055) and 6 months (P = .011). Longitudinal modeling of imputed data showed better preservation of all HVLT-R domains (P < .005). Patients who received HA-WBRT + Memantine reported less symptom burden at 6 (P < .001 using imputed data) and 12 months (P = .026 using complete-case data; P < .001 using imputed data), less symptom interference at 6 (P = .003 using complete-case data; P = .0016 using imputed data) and 12 months (P = .0027 using complete-case data; P = .0014 using imputed data), and fewer cognitive symptoms over time (P = .043 using imputed data). Treatment arms did not differ significantly in overall survival, intracranial progression-free survival, or toxicity. CONCLUSIONS With median follow-up exceeding 1 year, HA during WBRT + memantine for brain metastases leads to sustained preservation of cognitive function and continued prevention of patient-reported neurologic symptoms, symptom interference, and cognitive symptoms with no difference in survival or toxicity.
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Affiliation(s)
- Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Department of Radiation Oncology, Warrenville, Illinois.
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Paul D Brown
- Mayo Clinic, Department of Radiation Oncology, Rochester, Minnesota
| | - Jeffrey S Wefel
- University of Texas MD Anderson Cancer Center, Department of Neuro-Oncology, Houston, Texas
| | - Terri S Armstrong
- National Cancer Institute Center for Cancer Research, Bethesda, Maryland
| | - Wolfgang A Tome
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Mark R Gilbert
- University of Texas MD Anderson Cancer Center, Department of Neuro-Oncology, Houston, Texas
| | - Andre Konski
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Joseph A Bovi
- Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | | | | | - Isaac Kaufman
- Wayne State University/Karmanos Cancer Institute, Detroit, Michigan
| | - Sunjay Shah
- Delaware/Christiana Care National Cancer Institute Community Oncology Research Program, Wilmington, Delaware
| | | | | | | | - Lisa A Kachnic
- Columbia University, Vagelos Colleg of Physicians and Surgeons, New York, New York
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5
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Kinslow CJ, Rae AI, Taparra K, Kumar P, Siegelin MD, Grinband J, Gill BJA, McKhann GM, Sisti MB, Bruce JN, Canoll PD, Iwamoto FM, Horowitz DP, Kachnic LA, Neugut AI, Yu JB, Cheng SK, Wang TJC. MGMT Promoter Methylation Predicts Overall Survival after Chemotherapy for 1p/19q-Codeleted Gliomas. Clin Cancer Res 2023; 29:4399-4407. [PMID: 37611077 PMCID: PMC10872921 DOI: 10.1158/1078-0432.ccr-23-1295] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 05/03/2023] [Revised: 06/12/2023] [Accepted: 08/22/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE While MGMT promoter methylation (mMGMT) is predictive of response to alkylating chemotherapy and guides treatment decisions in glioblastoma, its role in grade 2 and 3 glioma remains unclear. Recent data suggest that mMGMT is prognostic of progression-free survival in 1p/19q-codeleted oligodendrogliomas, but an effect on overall survival (OS) has not been demonstrated. EXPERIMENTAL DESIGN We identified patients with newly diagnosed 1p/19q-codeleted gliomas and known MGMT promoter status in the National Cancer Database from 2010 to 2019. Multivariable Cox proportional hazards regression modeling was used to assess the effect of mMGMT on OS after adjusting for age, sex, race, comorbidity, grade, extent of resection, chemotherapy, and radiotherapy. RESULTS We identified 1,297 eligible patients, 938 (72.3%) of whom received chemotherapy in their initial course of treatment. The MGMT promoter was methylated in 1,009 (77.8%) patients. Unmethylated MGMT (uMGMT) was associated with worse survival compared with mMGMT [70% {95% confidence interval (CI), 64%-77%} vs. 81% (95% CI, 78%-85%); P < 0.001; adjusted HR (aHR), 2.35 (95% CI, 1.77-3.14)]. uMGMT was associated with worse survival in patients who received chemotherapy [63% (95% CI, 55-73%) vs. 80% (95% CI, 76%-84%); P < 0.001; aHR, 2.61 (95% CI, 1.89-3.60)] but not in patients who did not receive chemotherapy [P = 0.38; HR, 1.31 (95% CI, 0.71-2.42)]. Similar results were observed regardless of World Health Organization grade and after single- or multiagent chemotherapy. CONCLUSIONS Our study demonstrates an association between mMGMT and OS in 1p/19q-codeleted gliomas. MGMT promoter status should be considered as a stratification factor in future clinical trials of 1p/19q-codeleted gliomas that use OS as an endpoint.
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Affiliation(s)
- Connor J. Kinslow
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, BNH B011, New York, NY 10032
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
| | - Ali I. Rae
- Department of Neurological Surgery, Oregon Health & Sciences University, 3181 SW Sam Jackson Pkwy, Portland, OR 97239
| | - Kekoa Taparra
- Department of Radiation Oncology, Stanford University, 875 Blake Wilbur Drive, Stanford, CA 94305
| | - Prashanth Kumar
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, BNH B011, New York, NY 10032
| | - Markus D. Siegelin
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
- Departments of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St. Nicholas Ave Rm. 1001 New York, NY 10032
| | - Jack Grinband
- Program in Imaging and Cognitive Sciences, Columbia University, New York, New York 10032, USA
- David Mahoney Center for Brain and Behavior Research, Columbia University, New York, New York 10032, USA
| | - Brian J. A. Gill
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY 10032
| | - Guy M. McKhann
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY 10032
| | - Michael B. Sisti
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY 10032
| | - Jeffrey N. Bruce
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY 10032
| | - Peter D. Canoll
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
- Department of Radiation Oncology, Stanford University, 875 Blake Wilbur Drive, Stanford, CA 94305
| | - Fabio M. Iwamoto
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY 10032
| | - David P. Horowitz
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, BNH B011, New York, NY 10032
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
| | - Lisa A. Kachnic
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, BNH B011, New York, NY 10032
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
| | - Alfred I. Neugut
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
- Department of Medicine, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th St, New York, NY 10032
| | - James B. Yu
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, BNH B011, New York, NY 10032
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
| | - Simon K. Cheng
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, BNH B011, New York, NY 10032
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
| | - Tony J. C. Wang
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, BNH B011, New York, NY 10032
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY 10032
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Wang YF, Elliston C, Munbodh R, Savacool M, Tam J, Joseph J, Spina CS, Horowitz DP, Kachnic LA, Price M. Creation and Implementation of an Interdisciplinary Workflow for CBCT-Based Online Adaptive Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e736. [PMID: 37786139 DOI: 10.1016/j.ijrobp.2023.06.2262] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) CBCT-based online adaptive radiotherapy (OART) is an emerging treatment strategy to replan based on the anatomy of the day while the patient remains on the couch. OART is not just an add-on to the current workflow; it necessitates a new approach across the patient's path of care, from CT simulation to treatment delivery. OART requires the addition of duties to clinical personnel, strategies to create auto-plan templates, and monitoring the "black box" adaptation process. Studies have shown that OART implementation is limited by its resource-intensive nature and the risks associated with the treatment approach. We hypothesized that the implementation of an interdisciplinary, streamlined workflow and checklists would enhance the OART treatment efficiency, prevent medical errors from the adaptation, and minimize the burden on clinicians. MATERIALS/METHODS An interdisciplinary OART working group comprising radiation oncologists, medical physicists, dosimetrists, and therapists was created to enable weekly knowledge sharing, workflow design, implementation, and continuous process improvement. 213 adaptive sessions from 5 treatment sites (pancreas, bladder, prostate, rectum, anus) were treated on a CBCT-based OART platform in a single institutional study. An evaluation of the treatment safety and workflow time was performed for each adaptive session. RESULTS The OART workflow was divided into four sub-workflows: 1) pre-treatment site-specific template preparation, 2) pre-treatment initial planning and verification, 3) on-treatment procedure, and 4) post-treatment evaluation. The sub-processes involved 4, 8, 13, and 4 separate, sequentially tasks, respectively, and a total of 11 task checklists. The template preparation is a new process developed for site-specific, standardized physician template directives, automated planning template development, and testing for its accuracy and robustness. The planning templates generated high-quality initial plans automatically within minutes once structures were segmented on the planning CT. This process was replicated during treatment using the CBCT. The median (interquartile range) online procedure time, defined as the time from initial CBCT to plan approval, of the five treatment sites (pancreas, bladder, prostate, rectum, anus) was 22.1 (19.2-24.8) min, 16.5 (15.3-17.5) min, 14.7 (13.9-17.4) min, 17 (15.3-19.7) min, and 24 (21.4-25.8) min, respectively. Safety assessment determined that no treatment deviations were observed. CONCLUSION Creating an interdisciplinary, standardized workflow and checklists allowed the safe delivery of OART with clinically feasible online procedure time and significantly reduced initial planning time compared with traditional EBRT. The unique workflow is essential to minimize the burden on the care team, increase patient safety, and access to OART.
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Affiliation(s)
- Y F Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - C Elliston
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - R Munbodh
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Savacool
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - J Tam
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - J Joseph
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - C S Spina
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - D P Horowitz
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - L A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Price
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
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7
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Lee AW, Pasetsky J, Lavrova E, Wang YF, Sedor GJ, Li F, Gallitto M, Garrett MD, Elliston C, Price M, Kachnic LA, Horowitz DP. CT-Guided Online Adaptive Stereotactic Body Radiotherapy for Pancreas Ductal Adenocarcinoma: Dosimetric and Initial Clinical Experience. Int J Radiat Oncol Biol Phys 2023; 117:e312. [PMID: 37785126 DOI: 10.1016/j.ijrobp.2023.06.2340] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Retrospective analysis suggests that dose escalation to a biologically effective dose of more than 70 Gy may improve overall survival in patients with pancreatic ductal adenocarcinoma (PDAC), but such treatments in practice are limited by proximity of organs at risk (OARs). We hypothesized that CT-guided online adaptive radiotherapy (OART) can account for interfraction movement of OARs, reduce dose to OARs, and improve coverage of targets. MATERIALS/METHODS This is a single institution retrospective analysis of patients with PDAC treated with OART on a CBCT-based OART platform. All patients were treated to 40 Gy in 5 fractions. PTV overlapping with a 5 mm planning risk volume expansion on the stomach, duodenum and bowel received 25 Gy. Initial treatment plans were created conventionally. For each fraction, PTV and OAR volumes were recontoured with AI assistance after initial cone beam CT (CBCT). The adapted plan was calculated, underwent QA, and then compared to the scheduled plan. A second CBCT was obtained prior to delivery of the selected plan. Total treatment time (first CBCT to end of radiation delivery) and active physician time (first to second CBCT) were recorded. PTV_4000 V95%, PTV_2500 V95%, and D0.03 cc to stomach, duodenum and bowel were reported for scheduled (S) and adapted (A) plans. CTCAEv5.0 toxicities were recorded. Statistical analysis was performed using a two-sided T test and α of 0.05. RESULTS Seven patients with unresectable or locally-recurrent PDAC were analyzed, with a total of 35 fractions. Average total time was 33:00 minutes (22:25-49:40) and average active time was 22:48 minutes (14:15-39:34). All fractions were treated with adapted plans. All adapted plans met PTV_4000 V95.0% > 95.0% coverage goal and OAR dose constraints. Dosimetric data for scheduled and adapted plans per fraction are in Table 1. Median follow up was 1.7 months. 5 (71%) patients experienced either Grade 1 or 2 toxicities. No patients experienced Grade 3+ toxicities. CONCLUSION Daily OART significantly reduced dose OARs while achieving superior PTV coverage. Treatment was generally well tolerated with no grade 3+ acute toxicity, and required only 22:48 minutes on average of active physician time. Our initial clinical experience demonstrates OART allows for safe dose escalation in the treatment of PDAC.
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Affiliation(s)
- A W Lee
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - J Pasetsky
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - E Lavrova
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - Y F Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - G J Sedor
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - F Li
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Gallitto
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M D Garrett
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - C Elliston
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Price
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - L A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - D P Horowitz
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
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8
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Kinslow CJ, Rae A, Kumar P, Grinband J, Gill BJA, McKhann GM, Sisti MB, Bruce JN, Canoll P, Iwamoto F, Yu JB, Kachnic LA, Cheng SK, Wang TJC. MGMT Promoter Methylation Predicts Survival in 1p19q-Codeleted Gliomas after Chemotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e117. [PMID: 37784660 DOI: 10.1016/j.ijrobp.2023.06.902] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) MGMT promoter methylation (mMGMT) is predictive of response to alkylating chemotherapy in glioblastomas and used to guide treatment decisions. However, the role of MGMT promoter status in low-grade and anaplastic gliomas remains unclear due to molecular heterogeneity and the lack of sufficiently large datasets. We recently found that MGMT promoter methylation predicts progression-free survival in 1p19q-codeleted gliomas after alkylating chemotherapy in a meta-analysis of three prospective cohorts. There were not enough deaths to determine the effect on overall survival. Here, we query a large national database to determine the association between MGMT promoter methylation and overall survival in patients with 1p19q-codeleted gliomas. MATERIALS/METHODS We identified all patients with newly diagnosed gliomas in the National Cancer Database (NCDB) from 2010-2016 with 1p19q-codeletion and information on MGMT promoter methylation status. The cohort was stratified based on receipt of chemotherapy. Multivariable Cox proportional hazards regression modeling was used to assess the effect of MGMT promoter methylation status on overall survival after adjusting for age, sex, race, co-morbidity, grade, extent of resection, chemotherapy, and radiotherapy. RESULTS We identified 530 eligible patients, 373 (70.4%) of whom received chemotherapy in their initial course of treatment. The MGMT promoter was methylated in 400 (75.5%) patients. For all patients, unmethylated MGMT (uMGMT) was associated with poorer survival compared to mMGMT (75% survival time [75%ST] 45 months vs. not reached, P = .003, adjusted hazard ratio [aHR] 2.36 [95% confidence interval (95% CI) 1.53-3.62]). uMGMT was associated with poorer survival in patients who received chemotherapy (75%ST 22 vs. 66 months, P<.001, aHR 2.55 [95% CI 1.60-4.06]) but not in patients who did not receive chemotherapy (75%ST 110 months vs. not reached, P = 0.7, HR 1.24 [95% CI 0.40-3.81]). CONCLUSION To our knowledge, this is the first study to demonstrate an association between overall survival and MGMT promoter status in 1p19q-codeleted gliomas. MGMT promoter status should be used as a stratification factor in future clinical trials of 1p19q-codeleted gliomas that use overall survival as an endpoint.
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Affiliation(s)
- C J Kinslow
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - A Rae
- Oregon Health & Sciences University, Portland, OR
| | - P Kumar
- Columbia University, New York, NY
| | - J Grinband
- Department of Radiology, Columbia University Irving Medical Center, New York, NY
| | | | - G M McKhann
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY
| | - M B Sisti
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY
| | - J N Bruce
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY
| | - P Canoll
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | | | - J B Yu
- Saint Francis Radiation Oncology, Hartford, CT
| | | | - S K Cheng
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
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9
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Konski A, Deshmukh S, Klopp AH, Yeung AR, Westin SN, Thompson JS, Doncals DE, Cantuaria GHC, D'Souza DP, Chang A, Kundapur V, Mohan DS, Haas ML, Kim YB, Ferguson CL, Pugh SL, Kachnic LA, Bruner DW. Quality-adjusted survival in women with gynecologic malignancies receiving IMRT after surgery: A Ppatient Rreported Ooutcome study of NRG oncology's RTOG 1203. Gynecol Oncol 2023; 175:176-181. [PMID: 37393743 PMCID: PMC10527270 DOI: 10.1016/j.ygyno.2023.05.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/21/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION NRG/RTOG 1203 compared 3-D conformal radiotherapy (3D CRT) to intensity-modulated radiotherapy (IMRT) in patients with endometrial or cervical cancer requiring post-operative radiotherapy after hysterectomy. The purpose of this study was to report the first quality-adjusted survival analysis comparing the two treatments. METHODS NRG/RTOG 1203 randomized patients having undergone hysterectomy to either 3DCRT or IMRT. Stratification factors included RT dose, chemotherapy, and disease site. The EQ-5D, both index and visual analog scale (VAS), were obtained at baseline, 5 weeks after the start of RT, 4-6 weeks post RT and 1 and 3-years post RT. EQ-5D index and VAS scores along with quality-adjusted survival (QAS) were compared between treatment arms using the t-test at a two-sided significance level of 0.05. RESULTS NRG/RTOG 1203 enrolled 289 patients of which 236 consented to participate in the patient reported outcome (PRO) assessments. QAS was higher in women treated with IMRT, 1374 vs 1333 days (p = 0.5) compared to patients treated with 3DCRT, but this difference was not statistically different. Patients treated with IMRT had less of a decline in VAS score 5 weeks post RT, -5.04, compared to patients treated with 3DCRT, -7.48, although not statistically significant (p = 0.38). CONCLUSION This is the first report of the use of the EQ-5D comparing two radiotherapy techniques in the treatment of gynecologic malignancies after surgery. While there were no significant differences in QAS and VAS scores between patients who received IMRT vs. 3DCRT, RTOG 1203 was not powered to show statistical differences in these secondary endpoints.
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Affiliation(s)
- Andre Konski
- Department of Radiation Oncology, University of Pennsylvania, Senior Fellow Leonard Davis Institute of Health Economics, University of Pennsylvania, The Chester County Hospital, 701 E. Marshall Ave, West Chester, PA 19380, USA; Senior Fellow, Leonard Davis Institute for Health Economics, University of Pennsylvania, Department of Radiation Oncology, University of Pennsylvania, The Chester County Hospital, 701 E. Marshall Ave, West Chester, PA 19380, USA.
| | - Snehal Deshmukh
- American College of Radiology, NRG Statistical and Data Management Center, NRG Oncology, 50 South 16th Street, Suite 2800, Philadelphia, PA 19102, USA
| | - Ann H Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center, Division of Radiation Oncology, 1515 Holcombe Boulevard, The University of Texas, Unit 1422, Houston, TX 77030, USA
| | - Anamaria R Yeung
- Department of Radiation Oncology, University of Florida, 2000 Southwest Archer Road PO Box 100385 Gainesville, FL 32610, USA
| | - Shannon N Westin
- Department of Radiation Oncology, MD Anderson Cancer Center, Division of Radiation Oncology, 1515 Holcombe Boulevard, The University of Texas, Unit 1422, Houston, TX 77030, USA
| | - J Spencer Thompson
- Department of Radiation Oncology, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, 800 Northeast Tenth Street, Fifth Floor, Oklahoma City, OK 73104, USA
| | - Desiree E Doncals
- SUMMA Akron City Hospital/ Cooper Cancer Center, 161 North Forge Street, Suite G90, Akron, OH 44304, USA
| | - Guilherme H C Cantuaria
- Northside Hospital, University Gynecologic Oncology 960 Johnson Ferry Road Northeast Suite 130 Atlanta, GA 30342, USA
| | - David P D'Souza
- London Regional Cancer Program, London Health Sciences Centre, 339 Windermere Road, P.O. Box 5339, Stn Z, London, Ontario N6A 5A5, Canada
| | - Amy Chang
- Pamela Youde Nethersole Eastern Hospital, Main Block, Lok Man Rd, Chai Wan, Hong Kong
| | - Vijayananda Kundapur
- Saskatoon Cancer Center, University of Saskatchewan, 20 Campus Drive, Saskatoon, SK S7N 4H4, Canada
| | - Dasarahally S Mohan
- Kaiser Permanente Cancer Treatment Center, Department of Radiation Oncology, 220 Oyster Point Boulevard South, San Francisco, CA 94080, USA
| | - Michael L Haas
- Department of Radiation Oncology, McGlinn Cancer Institute Reading, Reading Hospital Radiation Oncology Department, 420 South Fifth Avenue West Reading, PA 19611, USA
| | - Yong Bae Kim
- Yonsei University Health System, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea
| | - Catherine L Ferguson
- Georgia Regents University, Augusta University Medical Center, Section of Hematology and Oncology, 1120 15th Street, BAA-5407 Augusta, GA 30912, USA
| | - Stephanie L Pugh
- American College of Radiology, NRG Statistical and Data Management Center, NRG Oncology, 50 South 16th Street, Suite 2800, Philadelphia, PA 19102, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University, Herbert Irving Comprehensive Cancer Center, NYP/Columbia University Medical Center, Department of Radiation Oncology, 622 West 168th Street, New York, NY 10032, USA
| | - Deborah W Bruner
- Emory University Hospital/Winship Cancer Institute, 1599, Clifton Road, Northeast, Fourth Floor, Atlanta, GA 30322, USA
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10
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Lukka HR, Deshmukh S, Bruner DW, Bahary JP, Lawton CAF, Efstathiou JA, Kudchadker RJ, Ponsky LE, Seaward SA, Dayes IS, Gopaul DD, Michalski JM, Delouya G, Kaplan ID, Horwitz EM, Roach M, Feng FY, Pugh SL, Sandler HM, Kachnic LA. Five-Year Patient-Reported Outcomes in NRG Oncology RTOG 0938, Evaluating Two Ultrahypofractionated Regimens for Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 116:770-778. [PMID: 36592721 PMCID: PMC10619484 DOI: 10.1016/j.ijrobp.2022.12.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/28/2022] [Accepted: 12/12/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE There is considerable interest in very short (ultrahypofractionated) radiation therapy regimens to treat prostate cancer based on potential radiobiological advantages, patient convenience, and resource allocation benefits. Our objective is to demonstrate that detectable changes in health-related quality of life measured by the bowel and urinary domains of the Expanded Prostate Cancer Index Composite (EPIC-50) were not substantially worse than baseline scores. METHODS AND MATERIALS NRG Oncology's RTOG 0938 is a nonblinded randomized phase 2 study of National Comprehensive Cancer Network low-risk prostate cancer in which each arm is compared with a historical control. Patients were randomized to 5 fractions (7.25 Gy in 2 week and a day [twice a week]) or 12 fractions (4.3Gy in 2.5 weeks [5 times a week]). Secondary objectives assessed patient-reported toxicity at 5 years using the EPIC. Chi-square tests were used to assess the proportion of patients with a deterioration from baseline of >5 points for bowel, >2 points for urinary, and >11 points for sexual score. RESULTS The study enrolled 127 patients to 5 fractions (121 eligible) and 128 patients to 12 fractions (125 eligible). The median follow-up for all patients at the time of analysis was 5.38 years. The 5-year frequency for >5 point change in bowel score were 38.4% (P = .27) and 23.4% (P = 0.98) for 5 and 12 fractions, respectively. The 5-year frequencies for >2 point change in urinary score were 46.6% (P = .15) and 36.4% (P = .70) for 5 and 12 fractions, respectively. For 5 fractions, 49.3% (P = .007) of patients had a drop in 5-year EPIC-50 sexual score of ≥11 points; for 12 fractions, 54% (P < .001) of patients had a drop in 5-year EPIC-50 sexual score of ≥11 points. Disease-free survival at 5 years is 89.6% (95% CI: 84.0-95.2) in the 5-fraction arm and 92.3% (95% CI: 87.4-97.1) in the 12-fraction arm. There was no late grade 4 or 5 treatment-related urinary or bowel toxicity. CONCLUSIONS This study confirms that, based on long-term changes in bowel and urinary domains and toxicity, the 5- and 12-fraction regimens are well tolerated. These ultrahypofractionated approaches need to be compared with current standard radiation therapy regimens.
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Affiliation(s)
- Himanshu R Lukka
- Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Canada.
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | - Jean-Paul Bahary
- Centre Hospitalier de l'Universite´ de Montreal (CHUM), Montreal, Canada
| | | | | | | | - Lee E Ponsky
- Case Western Reserve University, Cleveland, Ohio
| | | | - Ian S Dayes
- Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Canada
| | | | | | - Guila Delouya
- Centre Hospitalier de l'Universite´ de Montreal (CHUM), Montreal, Canada
| | | | | | - Mack Roach
- University of California-San Francisco Medical Center, San Francisco, California
| | - Felix Y Feng
- University of California-San Francisco Medical Center, San Francisco, California
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | - Lisa A Kachnic
- Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Canada
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11
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Lavrova E, Garrett MD, Wang YF, Chin C, Elliston C, Savacool M, Price M, Kachnic LA, Horowitz DP. Adaptive Radiation Therapy: A Review of CT-based Techniques. Radiol Imaging Cancer 2023; 5:e230011. [PMID: 37449917 PMCID: PMC10413297 DOI: 10.1148/rycan.230011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/18/2023] [Accepted: 05/10/2023] [Indexed: 07/18/2023]
Abstract
Adaptive radiation therapy is a feedback process by which imaging information acquired over the course of treatment, such as changes in patient anatomy, can be used to reoptimize the treatment plan, with the end goal of improving target coverage and reducing treatment toxicity. This review describes different types of adaptive radiation therapy and their clinical implementation with a focus on CT-guided online adaptive radiation therapy. Depending on local anatomic changes and clinical context, different anatomic sites and/or disease stages and presentations benefit from different adaptation strategies. Online adaptive radiation therapy, where images acquired in-room before each fraction are used to adjust the treatment plan while the patient remains on the treatment table, has emerged to address unpredictable anatomic changes between treatment fractions. Online treatment adaptation places unique pressures on the radiation therapy workflow, requiring high-quality daily imaging and rapid recontouring, replanning, plan review, and quality assurance. Generating a new plan with every fraction is resource intensive and time sensitive, emphasizing the need for workflow efficiency and clinical resource allocation. Cone-beam CT is widely used for image-guided radiation therapy, so implementing cone-beam CT-guided online adaptive radiation therapy can be easily integrated into the radiation therapy workflow and potentially allow for rapid imaging and replanning. The major challenge of this approach is the reduced image quality due to poor resolution, scatter, and artifacts. Keywords: Adaptive Radiation Therapy, Cone-Beam CT, Organs at Risk, Oncology © RSNA, 2023.
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Affiliation(s)
- Elizaveta Lavrova
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Matthew D. Garrett
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Yi-Fang Wang
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Christine Chin
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Carl Elliston
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Michelle Savacool
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Michael Price
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Lisa A. Kachnic
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - David P. Horowitz
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
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12
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Kinslow CJ, Yu JB, DeStephano DM, Kachnic LA, Cheng SK, Neugut AI, Horowitz DP. Risk of Squamous Cell Carcinoma of the Breast Following Postmastectomy Implant Reconstruction in Women With Breast Cancer and Carcinoma in Situ. JAMA Surg 2023; 158:769-771. [PMID: 37074722 PMCID: PMC10116379 DOI: 10.1001/jamasurg.2023.0262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/17/2023] [Indexed: 04/20/2023]
Abstract
This cohort study uses national surveillance data to describe the incidence and risk of squamous cell carcinoma after postmastectomy implant reconstruction in women with breast cancer.
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Affiliation(s)
- Connor J. Kinslow
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - James B. Yu
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - David M. DeStephano
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Lisa A. Kachnic
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Simon K. Cheng
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Alfred I. Neugut
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - David P. Horowitz
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
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13
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Kinslow CJ, Mercurio A, Kumar P, Rae AI, Siegelin MD, Grinband J, Taparra K, Upadhyayula PS, McKhann GM, Sisti MB, Bruce JN, Canoll PD, Iwamoto FM, Kachnic LA, Yu JB, Cheng SK, Wang TJC. Association of MGMT Promoter Methylation With Survival in Low-grade and Anaplastic Gliomas After Alkylating Chemotherapy. JAMA Oncol 2023; 9:919-927. [PMID: 37200021 PMCID: PMC10196932 DOI: 10.1001/jamaoncol.2023.0990] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 10/17/2022] [Accepted: 02/13/2023] [Indexed: 05/19/2023]
Abstract
Importance O6-methylguanine-DNA methyltransferase (MGMT [OMIM 156569]) promoter methylation (mMGMT) is predictive of response to alkylating chemotherapy for glioblastomas and is routinely used to guide treatment decisions. However, the utility of MGMT promoter status for low-grade and anaplastic gliomas remains unclear due to molecular heterogeneity and the lack of sufficiently large data sets. Objective To evaluate the association of mMGMT for low-grade and anaplastic gliomas with chemotherapy response. Design, Setting, and Participants This cohort study aggregated grade II and III primary glioma data from 3 prospective cohort studies with patient data collected from August 13, 1995, to August 3, 2022, comprising 411 patients: MSK-IMPACT, EORTC (European Organization of Research and Treatment of Cancer) 26951, and Columbia University. Statistical analysis was performed from April 2022 to January 2023. Exposure MGMT promoter methylation status. Main Outcomes and Measures Multivariable Cox proportional hazards regression modeling was used to assess the association of mMGMT status with progression-free survival (PFS) and overall survival (OS) after adjusting for age, sex, molecular class, grade, chemotherapy, and radiotherapy. Subgroups were stratified by treatment status and World Health Organization 2016 molecular classification. Results A total of 411 patients (mean [SD] age, 44.1 [14.5] years; 283 men [58%]) met the inclusion criteria, 288 of whom received alkylating chemotherapy. MGMT promoter methylation was observed in 42% of isocitrate dehydrogenase (IDH)-wild-type gliomas (56 of 135), 53% of IDH-mutant and non-codeleted gliomas (79 of 149), and 74% of IDH-mutant and 1p/19q-codeleted gliomas (94 of 127). Among patients who received chemotherapy, mMGMT was associated with improved PFS (median, 68 months [95% CI, 54-132 months] vs 30 months [95% CI, 15-54 months]; log-rank P < .001; adjusted hazard ratio [aHR] for unmethylated MGMT, 1.95 [95% CI, 1.39-2.75]; P < .001) and OS (median, 137 months [95% CI, 104 months to not reached] vs 61 months [95% CI, 47-97 months]; log-rank P < .001; aHR, 1.65 [95% CI, 1.11-2.46]; P = .01). After adjusting for clinical factors, MGMT promoter status was associated with chemotherapy response in IDH-wild-type gliomas (aHR for PFS, 2.15 [95% CI, 1.26-3.66]; P = .005; aHR for OS, 1.69 [95% CI, 0.98-2.91]; P = .06) and IDH-mutant and codeleted gliomas (aHR for PFS, 2.99 [95% CI, 1.44-6.21]; P = .003; aHR for OS, 4.21 [95% CI, 1.25-14.2]; P = .02), but not IDH-mutant and non-codeleted gliomas (aHR for PFS, 1.19 [95% CI, 0.67-2.12]; P = .56; aHR for OS, 1.07 [95% CI, 0.54-2.12]; P = .85). Among patients who did not receive chemotherapy, mMGMT status was not associated with PFS or OS. Conclusions and Relevance This study suggests that mMGMT is associated with response to alkylating chemotherapy for low-grade and anaplastic gliomas and may be considered as a stratification factor in future clinical trials of patients with IDH-wild-type and IDH-mutant and codeleted tumors.
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Affiliation(s)
- Connor J. Kinslow
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Ann Mercurio
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Prashanth Kumar
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Ali I. Rae
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland
| | - Markus D. Siegelin
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Department of Pathology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Department of Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Jack Grinband
- Department of Psychiatry, Columbia University, New York, New York
- Department of Radiology, Columbia University, New York, New York
| | - Kekoa Taparra
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Pavan S. Upadhyayula
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Guy M. McKhann
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Michael B. Sisti
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Jeffrey N. Bruce
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Peter D. Canoll
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Department of Pathology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Department of Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Fabio M. Iwamoto
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Lisa A. Kachnic
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - James B. Yu
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Simon K. Cheng
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Tony J. C. Wang
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
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14
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Ryu S, Deshmukh S, Timmerman RD, Movsas B, Gerszten P, Yin FF, Dicker A, Abraham CD, Zhong J, Shiao SL, Tuli R, Desai A, Mell LK, Iyengar P, Hitchcock YJ, Allen AM, Burton S, Brown D, Sharp HJ, Dunlap NE, Siddiqui MS, Chen TH, Pugh SL, Kachnic LA. Stereotactic Radiosurgery vs Conventional Radiotherapy for Localized Vertebral Metastases of the Spine: Phase 3 Results of NRG Oncology/RTOG 0631 Randomized Clinical Trial. JAMA Oncol 2023; 9:800-807. [PMID: 37079324 PMCID: PMC10119775 DOI: 10.1001/jamaoncol.2023.0356] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/23/2023] [Indexed: 04/21/2023]
Abstract
Importance Spine metastasis can be treated with high-dose radiation therapy with advanced delivery technology for long-term tumor and pain control. Objective To assess whether patient-reported pain relief was improved with stereotactic radiosurgery (SRS) as compared with conventional external beam radiotherapy (cEBRT) for patients with 1 to 3 sites of vertebral metastases. Design, Setting, and Participants In this randomized clinical trial, patients with 1 to 3 vertebral metastases were randomized 2:1 to the SRS or cEBRT groups. This NRG 0631 phase 3 study was performed as multi-institutional enrollment within NRG Oncology. Eligibility criteria included the following: (1) solitary vertebral metastasis, (2) 2 contiguous vertebral levels involved, or (3) maximum of 3 separate sites. Each site may involve up to 2 contiguous vertebral bodies. A total of 353 patients enrolled in the trial, and 339 patients were analyzed. This analysis includes data extracted on March 9, 2020. Interventions Patients randomized to the SRS group were treated with a single dose of 16 or 18 Gy (to convert to rad, multiply by 100) given to the involved vertebral level(s) only, not including any additional spine levels. Patients assigned to cEBRT were treated with 8 Gy given to the involved vertebra plus 1 additional vertebra above and below. Main Outcomes and Measures The primary end point was patient-reported pain response defined as at least a 3-point improvement on the Numerical Rating Pain Scale (NRPS) without worsening in pain at the secondary site(s) or the use of pain medication. Secondary end points included treatment-related toxic effects, quality of life, and long-term effects on vertebral bone and spinal cord. Results A total of 339 patients (mean [SD] age of SRS group vs cEBRT group, respectively, 61.9 [13.1] years vs 63.7 [11.9] years; 114 [54.5%] male in SRS group vs 70 [53.8%] male in cEBRT group) were analyzed. The baseline mean (SD) pain score at the index vertebra was 6.06 (2.61) in the SRS group and 5.88 (2.41) in the cEBRT group. The primary end point of pain response at 3 months favored cEBRT (41.3% for SRS vs 60.5% for cEBRT; difference, -19 percentage points; 95% CI, -32.9 to -5.5; 1-sided P = .99; 2-sided P = .01). Zubrod score (a measure of performance status ranging from 0 to 4, with 0 being fully functional and asymptomatic, and 4 being bedridden) was the significant factor influencing pain response. There were no differences in the proportion of acute or late adverse effects. Vertebral compression fracture at 24 months was 19.5% with SRS and 21.6% with cEBRT (P = .59). There were no spinal cord complications reported at 24 months. Conclusions and Relevance In this randomized clinical trial, superiority of SRS for the primary end point of patient-reported pain response at 3 months was not found, and there were no spinal cord complications at 2 years after SRS. This finding may inform further investigation of using spine radiosurgery in the setting of oligometastases, where durability of cancer control is essential. Trial Registration ClinicalTrials.gov Identifier: NCT00922974.
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Affiliation(s)
- Samuel Ryu
- Department of Radiation Oncology, Stony Brook University Health Science Center, Stony Brook, New York
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
- American College of Radiology, Philadelphia, Pennsylvania
| | | | | | - Peter Gerszten
- University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | | | - Adam Dicker
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Jim Zhong
- Emory University Hospital, Atlanta, Georgia
| | | | | | - Anand Desai
- Summa Akron City Hospital/Cooper Cancer Center, Akron, Ohio
| | - Loren K. Mell
- University of California San Diego Moores Cancer Center, La Jolla
| | - Puneeth Iyengar
- University of Texas Southwestern/Simmons Cancer Center–Dallas
| | | | | | - Steven Burton
- University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Doris Brown
- Wake Forest University Health Sciences, Winston Salem, North Carolina
| | | | - Neal E. Dunlap
- The James Graham Brown Cancer Center at University of Louisville, Louisville, Kentucky
| | | | | | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
- American College of Radiology, Philadelphia, Pennsylvania
| | - Lisa A. Kachnic
- Columbia University Irving Medical Center, New York, New York
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15
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Gholami S, Colby S, Horowitz DP, Guthrie KA, Ben-Josef E, El-Khoueiry AB, Blanke CD, Philip PA, Kachnic LA, Ahmad SA, Rocha FG. ASO Visual Abstract: Adjuvant Chemoradiation in Patients with Lymph Node-Positive Biliary Tract Cancers - Secondary Analysis of a Single-Arm Clinical Trial (SWOG 0809). Ann Surg Oncol 2023; 30:1364-1365. [PMID: 36542251 DOI: 10.1245/s10434-022-12927-w] [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: 12/24/2022]
Affiliation(s)
- Sepideh Gholami
- Department of Surgery, University of California, Sacramento, Davis, CA, USA.
| | - Sarah Colby
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - David P Horowitz
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York City, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York City, NY, USA
| | - Katherine A Guthrie
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Edgar Ben-Josef
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony B El-Khoueiry
- Department of Clinical Medicine, University of Southern California, Los Angeles, CA, USA
| | - Charles D Blanke
- SWOG Group Chair's Office, Knight Cancer Institute, Oregon Health Sciences University, Portland, OR, USA
| | - Philip A Philip
- Department of Oncology and Department of Pharmacology, School of Medicine, Karmanos Cancer Center, Wayne State University, Detroit, MI, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York City, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York City, NY, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Flavio G Rocha
- Division of Surgical Oncology, Knight Cancer Institute, Oregon Health Sciences University, Portland, OR, USA
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16
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Garrett MD, Li F, Lemus OD, Lavrova E, Savacool M, Price MJ, Kachnic LA, Horowitz DP, Chin C. Impact of Adapted Radiotherapy Schedules on Bowel Sparing in Node-Positive Cervical Cancer. Pract Radiat Oncol 2023; 13:e184-e191. [PMID: 36539155 DOI: 10.1016/j.prro.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Definitive radiation therapy (RT) for locally advanced node-positive cervical cancer confers significant toxicity to pelvic organs including the small bowel. Gross nodal disease exhibits significant shrinkage during RT, and yet conventional RT does not account for this change. We evaluated the reduction in absorbed bowel dose using various adaptive RT schedules. METHODS AND MATERIALS We obtained 130 evaluable scans (computed tomography simulation and 25 cone beam computed tomography scans per patient) of 5 patients who had received definitive external beam RT for lymph node positive cervical cancer daily over 5 weeks. Using a single universal volumetric modulated arc therapy plan with predefined optimization priorities, we created adapted RT plans in 4 schedules: Daily, Weekly, Twice, and NoAdapt (mimicking conventional nonadapted RT). The in silico (computer modeled) patients were treated to 45 Gy to primary cervical disease with a simultaneous integrated boost to 55 Gy to involved lymph nodes. We evaluated dose metrics including D2cc, D15cc, and V45 to determine the impact of adapted RT schedules on bowel sparing. Statistical tests included the Student t test, analysis of variance, and the Spearman rank correlation. RESULTS The quantity of reduced bowel dose was significantly associated with the chosen planning schedule in all evaluated metrics and was proportional to the frequency of adaptive RT with significant moderate-to-strong monotonicity. Both D2cc and D15cc were reduced an average of 2.7 Gy using daily replanning compared with a nonadapted approach. A minimally adapted strategy of only 2 replans also confers a significant dosimetric benefit over a nonadapted approach. Reduced standard deviations of D2cc and V45 bowel doses over the treatment courses were significantly associated with the choice of planning schedule with strong monotonicity. CONCLUSIONS All adaptive RT schedules evaluated confer significant dosimetric advantages in bowel sparing over a conventional nonadapted technique, with greater sparing seen with more frequent replanning schedules. These findings warrant future trials of adaptive RT for pelvic malignancies.
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Affiliation(s)
- Matthew D Garrett
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York
| | - Fiona Li
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York
| | - Olga Dona Lemus
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Elizaveta Lavrova
- Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Michelle Savacool
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York
| | - Michael J Price
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - David P Horowitz
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Christine Chin
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.
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17
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Gholami S, Colby S, Horowitz DP, Guthrie KA, Ben-Josef E, El-Khoueiry AB, Blanke CD, Philip PA, Kachnic LA, Ahmad SA, Rocha FG. Adjuvant Chemoradiation in Patients with Lymph Node-Positive Biliary Tract Cancers: Secondary Analysis of a Single-Arm Clinical Trial (SWOG 0809). Ann Surg Oncol 2023; 30:1354-1363. [PMID: 36622529 PMCID: PMC10695673 DOI: 10.1245/s10434-022-12863-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/10/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND SWOG 0809 is the only prospective study of adjuvant chemotherapy followed by chemoradiation focusing on margin status in patients with extrahepatic cholangiocarcinoma (EHCC) and gallbladder cancer (GBCA); however, the effects of adjuvant therapy by nodal status have never been reported in this population. METHODS Patients with resected EHCC and GBCA, stage pT2-4, node-positive (N+) or margin-positive (R1) who completed four cycles of chemotherapy followed by radiotherapy were included. Cox regression was used to compare overall survival (OS), disease-free survival (DFS), local recurrence, and distant metastasis by nodal status. DFS rates were compared with historical data via a one-sample t-test. RESULTS Sixty-nine patients [EHCC, n = 46 (66%); GBCA, n = 23 (33%)] were evaluated, with a median age of 61.7 years and an R0 rate of 66.7% and R1 rate of 33.3%. EHCC versus GBCA was more likely to be N+ (73.9% vs. 47.8%, p = 0.03). Nodal status did not significantly impact OS (hazard ratio [HR] 1.98, 95% confidence interval [CI] 0.86-4.54, p = 0.11) or DFS (HR 1.63, 95% CI 0.77-3.44, p = 0.20). Two-year OS was 70.6% for node-negative (N0) disease and 60.9% for N+ disease, while 2-year DFS was 62.5% for N0 tumors and 49.8% for N+ tumors. N+ versus N0 tumors showed higher rates of distant failure (42.2% vs. 25.0%, p = 0.04). The 2-year DFS rate in N+ tumors was significantly higher than in historical controls (49.8% vs. 29.7%, p = 0.004). CONCLUSIONS Adjuvant therapy is associated with favorable outcome independent of nodal status and may impact local control in N+ patients. These data could serve as a benchmark for future adjuvant trials, including molecular-targeted agents.
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Affiliation(s)
- Sepideh Gholami
- Department of Surgery, University of California, Davis, CA, USA.
| | - Sarah Colby
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - David P Horowitz
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York City, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York City, NY, USA
| | - Katherine A Guthrie
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Edgar Ben-Josef
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony B El-Khoueiry
- Department of Clinical Medicine, University of Southern California, Los Angeles, CA, USA
| | - Charles D Blanke
- SWOG Group Chair's Office, Oregon Health Sciences University, Knight Cancer Institute, Portland, OR, USA
| | - Philip A Philip
- Department of Oncology and Department of Pharmacology, School of Medicine, Wayne State University, Karmanos Cancer Center, Detroit, MI, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York City, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York City, NY, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Flavio G Rocha
- Division of Surgical Oncology, Oregon Health Sciences University, Knight Cancer Institute, Portland, OR, USA
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18
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Rayn K, Elliston C, Savacool M, Fang Y, Deutsch I, Spina CS, Kachnic LA, Yu JB. Physician-driven artificial intelligence enabled planning for intraprostatic dose escalation in under ten minutes. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.187] [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: 03/16/2023] Open
Abstract
187 Background: Intraprostatic radiation dose escalation is an area of clinical interest. Dose escalation within the prostate must be balanced with maintaining acceptable dose to the organs at risk, OAR (bladder, rectum, and urethra). Treatment planning therefore requires simultaneous consideration of multiple competing plan optimization goals, for which iterative, interdisciplinary treatment planning tasks may take significant physician, physicist, and dosimetrist time. Semi-automated treatment planning using artificial intelligence has the potential to significantly reduce treatment planning time for technically complex treatments. Methods: A prostate SBRT planning template was created using the Varian ETHOS treatment planning system (TPS) combined with an in-house RapidPlan SBRT prostate model. Prostate dose was prescribed to 36.25 Gy over 5 fractions with 95% coverage to the PTV. To respect standard SBRT normal tissue toxicity constraints while simultaneously escalating intraprostatic dose, the TPS automatically created an intraprostatic boost structure (PTV_SIB), derived from the PTV by excluding OARs with a pre-determined margin. Physicians were trained to perform treatment planning using the prostate SBRT planning template. Treatment planning was performed on 5 unique patients. The time spent from initiation to end of treatment planning and dosimetric parameters were recorded. Results: For each patient, the ETHOS TPS generated two SBRT plans (9 field static IMRT and 3 VMAT arc) with intraprostatic dose escalation in an average of 9.3 minutes [range 8.4-11.8]. Static field and VMAT plans were comparable. PTV_SIB was escalated to above 50 Gy in all cases. Relevant dosimetry for each patient’s static IMRT plan is shown. Conclusions: Physician-driven ETHOS treatment planning was able to produce boosted internal PTV doses using autosegmented volumes. The ETHOS TPS was able to generate dose-escalated plans that reconciled complex OAR and PTV goals within 8-12 minutes. Hence, the ETHOS TPS opens the possibility of rapid physician-driven treatment planning throughput. [Table: see text]
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Affiliation(s)
- Kareem Rayn
- New York Presbyterian - Columbia, New York, NY
| | | | | | - Yi Fang
- New York Presbyterian - Columbia, New York, NY
| | | | | | | | - James B. Yu
- New York Presbyterian - Columbia, New York, NY
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19
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Dawson LA, Winter KA, Knox JJ, Zhu AX, Krishnan S, Guha C, Kachnic LA, Gillin M, Hong TS, Craig T, Hosni A, Chen EX, Noonan AM, Koay EJ, Sinha R, Lock M, Ohri N, Dorth JA, Moughan J, Crane CH. NRG/RTOG 1112: Randomized phase III study of sorafenib vs. stereotactic body radiation therapy (SBRT) followed by sorafenib in hepatocellular carcinoma (HCC). J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.489] [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: 01/25/2023] Open
Abstract
489 Background: To determine if SBRT followed by sorafenib (SBRT/S) improves overall survival (OS), progression free survival (PFS) and quality of life (QOL) vs. sorafenib alone (S), in patients (pts) with HCC. Methods: Eligible pts had new or recurrent HCC, unsuitable for surgery, ablation or TACE, with Zubrod performance status (PS) 0-2, Child-Pugh (CP) A, BCLC stage B or C, ≤ 5 HCCs, sum of hepatic HCCs ≤ 20 cm, and distant metastases ≤ 3 cm. Pts were randomized 1:1 to S 400 mg BID vs. SBRT (27.5-50 Gy in 5 fractions) followed by S 200 mg BID, increased to 400 mg BID after 28 days. Primary endpoint was OS; reported secondary endpoints - PFS, adverse events (AEs - CTCAEv4), and QOL (improvement in FACT-Hep score by ≥ 5 points from baseline to 6 months). Planned sample size was 292 pts (238 OS events, HR=0.72, 80% power, 1-sided α=0.05). Accrual closed early, due to a change in HCC standard of care. Statistics were amended to report as of 7/1/2022, projecting 155 OS events, with 65% power and the same α. OS and PFS were estimated by Kaplan-Meier and arms compared using log-rank test. Cox proportional hazards models were used to analyze treatment effect. Secondary endpoints were tested with 2-sided α=0.05. Results: Of 193 pts accrued from April 2013 to March 2021 from 23 sites, 177 eligible pts were randomized to S (n=92) vs. SBRT/S (n=85). Median age was 66 yrs (27-84); 41% had Hep. C; 19% had Hep. B or B/C. 82% were BCLC stage C. 74% had macrovascular invasion (MVI), 63% with VP3 or VP4 MVI. 4% had metastases. Median sum of max diameter of HCCs was 8.2 cm for S and 6.7 cm for SBRT/S; 40% had a single HCC. Median follow-up for all and alive pts was 13.2 and 33.7 mo. 22% of S pts received SBRT after discontinuing S. With 153 OS events, median OS was improved from 12.3 mo. (90% CI 10.6, 14.3) with S to 15.8 mo. (90% CI 11.4-19.2) with SBRT/S (HR=0.77, 1-sided p=0.0554). After adjusting for PS, M stage, CP A5 vs. 6, and degree of MVI, OS was statistically significantly improved for SBRT/S (HR=0.72, 95% CI 0.52-0.99, 2-sided Cox p=0.042). Median PFS was improved from 5.5 mo. (95% CI 3.4-6.3) with S to 9.2 months (95% CI 7.5-11.9) with SBRT/S (HR=0.55, 95% CI 0.40-0.75, 2-sided p=0.0001). 8 grade (G) 3+ bleeds were seen: 5 in S arm (1 G3 variceal, 2 G3 upper GI, 1 G3 hepatic, and 1 G4 abdominal) and 3 post SBRT/S (2 G3 upper GI, 1 G3 lower GI). Treatment-related G3+ AEs were not significantly different (S - 42%; SBRT/S - 47%; p=0.52), with 3 G5 AEs (S - 1 hepatic failure, 1 death NOS; SBRT/S - 1 lung infection). 83 (47%) pts consented to QoL. Of 20 S and 17 SBRT/S pts with QoL assessments at baseline and 6 months, 10% on S improved in FACT-Hep score vs 35% on SBRT/S. Conclusions: Compared to S alone, SBRT improved OS & PFS in patients with HCC, with no observed increase in AEs, and a strong suggestion for QOL benefit at 6 months. Supported by U10CA180868 (NRG Onc. Op., U10CA180822 (NRG Onc. SDMC), UG1CA189867 (NCORP), and U24CA180803 (IROC) from the NCI. Clinical trial information: NCT01730937 .
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Affiliation(s)
| | | | - Jennifer J. Knox
- Princess Margaret - University Health Network, Toronto, ON, Canada
| | | | | | - Chandan Guha
- Montefiore Einstein Center for Cancer Care, Bronx, NY
| | | | - Michael Gillin
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Timothy Craig
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Ali Hosni
- Princess Margaret - University Health Network, Toronto, ON, Canada
| | | | - Anne M. Noonan
- James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Eugene Jon Koay
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rishi Sinha
- Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Michael Lock
- London Regional Cancer Centre, London, ON, Canada
| | - Nitin Ohri
- Albert Einstein College of Medicine, Bronx, NY
| | - Jennifer Anne Dorth
- University Hospitals Seidman Cancer Center, and Case Western Reserve University Comprehensive Cancer Center LAPS, Cleveland, OH
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20
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Linet MS, Applegate KE, McCollough CH, Bailey JE, Bright C, Bushberg JT, Chanock SJ, Coleman J, Dalal NH, Dauer LT, Davis PB, Eagar RY, Frija G, Held KD, Kachnic LA, Kiess AP, Klein LW, Kosti O, Miller CW, Miller-Thomas MM, Straus C, Vapiwala N, Wieder JS, Yoo DC, Brink JA, Dalrymple JL. A Multimedia Strategy to Integrate Introductory Broad-Based Radiation Science Education in US Medical Schools. J Am Coll Radiol 2023; 20:251-264. [PMID: 36130692 PMCID: PMC10578400 DOI: 10.1016/j.jacr.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 12/27/2022]
Abstract
US physicians in multiple specialties who order or conduct radiological procedures lack formal radiation science education and thus sometimes order procedures of limited benefit or fail to order what is necessary. To this end, a multidisciplinary expert group proposed an introductory broad-based radiation science educational program for US medical schools. Suggested preclinical elements of the curriculum include foundational education on ionizing and nonionizing radiation (eg, definitions, dose metrics, and risk measures) and short- and long-term radiation-related health effects as well as introduction to radiology, radiation therapy, and radiation protection concepts. Recommended clinical elements of the curriculum would impart knowledge and practical experience in radiology, fluoroscopically guided procedures, nuclear medicine, radiation oncology, and identification of patient subgroups requiring special considerations when selecting specific ionizing or nonionizing diagnostic or therapeutic radiation procedures. Critical components of the clinical program would also include educational material and direct experience with patient-centered communication on benefits of, risks of, and shared decision making about ionizing and nonionizing radiation procedures and on health effects and safety requirements for environmental and occupational exposure to ionizing and nonionizing radiation. Overarching is the introduction to evidence-based guidelines for procedures that maximize clinical benefit while limiting unnecessary risk. The content would be further developed, directed, and integrated within the curriculum by local faculties and would address multiple standard elements of the Liaison Committee on Medical Education and Core Entrustable Professional Activities for Entering Residency of the Association of American Medical Colleges.
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Affiliation(s)
- Martha S Linet
- Chief and Senior Investigator, Radiation Epidemiology Branch (retired) and currently NIH Scientist Emerita, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Kimberly E Applegate
- Division Chief and Professor of Pediatric Radiology (retired), University of Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky, and currently Chair of Committee 3 of the International Commission on Radiological Protection, Ottawa, Canada
| | - Cynthia H McCollough
- Brooks-Hollern Professor of Medical Physics and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Janet E Bailey
- Professor of Radiology and Associate Chair for Education in Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Cedric Bright
- Associate Dean for Admissions and Clinical Professor, Department of Internal Medicine, East Carolina's Brody School of Medicine, Greenville, North Carolina
| | - Jerrold T Bushberg
- Clinical Professor of Radiology and Radiation Oncology, University of California Davis School of Medicine, Sacramento, California, and Vice President, National Council of Radiation Protection and Measurements, Bethesda, Maryland
| | - Stephen J Chanock
- Director and Chief of the Cancer Genomics Research Laboratory, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jenna Coleman
- Executive Director of the Medical Educational Council of Pensacola, Pensacola, Florida
| | - Nicole H Dalal
- Resident, Department of Internal Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - Lawrence T Dauer
- Attending Physicist, Departments of Medical Physics and Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pamela B Davis
- Dean School of Medicine (emerita) and Arline H. and Curtis F. Garvin Research Professor, Center for Community Health Integration, and Professor of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert Y Eagar
- Diagnostic Radiology Resident, Department of Radiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Guy Frija
- Professor of Radiology (Emeritus), Université de Paris, Paris, France
| | - Kathryn D Held
- President of the National Council on Radiation Protection and Measurements, Bethesda, Maryland, and Associate Radiation Biologist, Department of Radiation Oncology, Massachusetts General Hospital and Associate Professor of Radiation Oncology, Harvard Medical School, Boston, Massachusetts
| | - Lisa A Kachnic
- Chair, Department of Radiation Oncology, Columbia University Medical Center and the Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Ana P Kiess
- Assistant Professor of Radiation Oncology and Molecular Radiation Sciences and Director of the Residency Program, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lloyd W Klein
- Clinical Professor of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - Ourania Kosti
- Senior Program Officer at the Nuclear and Radiation Studies Board of the National Academies of Sciences, Engineering, and Medicine, Washington, DC
| | - Charles W Miller
- Chief (retired) Radiation Studies Branch, Division of Environmental Hazards and Health Effects, Centers for Disease Control and Prevention, Atlanta, Georgia, and currently a Consultant in Nuclear and Radiological Environmental Health, Atlanta, Georgia
| | - Michelle M Miller-Thomas
- Associate Professor of Radiology and Director of Medical Student Education at Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Christopher Straus
- Associate Professor of Radiology and Director of Medical Student Education, University of Chicago School of Medicine, Chicago, Illinois
| | - Neha Vapiwala
- Professor and Vice Chair of Education, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica S Wieder
- Director of the Center for Radiation Information and Outreach, US Environmental Protection Agency, Washington, DC
| | - Don C Yoo
- Director of Nuclear Medicine, Miriam Hospital and Professor of Diagnostic Imaging and Clinical Educator, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - James A Brink
- Chair, Department of Radiology, Brigham and Women's Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John L Dalrymple
- Professor of Obstetrics, Gynecology and Reproductive Biology and Associate Dean for Medical Education Quality Improvement, Harvard Medical School, Boston, Massachusetts, and Associate Chair and Vice Chair for Faculty Development and Faculty Affairs and Gynecologic Oncology Fellowship Program Director, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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21
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George TJ, Yothers G, Rahma OE, Hong TS, Russell MM, You YN, Parker W, Jacobs SA, Lucas PC, Colangelo LH, Gollub MJ, Hall WA, Kachnic LA, Bajaj M, Gross HM, Peterson RA, Dorth JA, Vijayvergia N, Wolmark N. Long-term results from NRG-GI002: A phase II clinical trial platform using total neoadjuvant therapy (TNT) in locally advanced rectal cancer (LARC). J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.7] [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: 01/25/2023] Open
Abstract
7 Background: This NCTN multi-arm randomized phase II modular clinical trial platform utilizes TNT with parallel experimental arms (EAs) in LARC. EAs are not intended for direct comparison, but rather to concurrently randomized control arm (CA) patients. Primary endpoint (EP) and available secondary EPs (from EA1 using veliparib [V], PARPi; and EA2 using pembrolizumab [P], anti-PD-1) have been previously reported. We present long-term outcomes of all pts enrolled (NCT02921256). Methods: Stage II/III pts with MSS LARC (with any ONE of the following: distal location [cT3-4 ≤5cm from anal verge, any N]; bulky [any cT4 or tumor within 3mm of mesorectal fascia]; high risk for metastatic disease [cN2]; or not a sphincter-sparing surgery [SSS] candidate) were randomized to CA (neoadjuvant FOLFOX [x 4mo] → chemoRT [capecitabine with 50.4Gy] → surgery 8-12 wks later). EA1 added V (400mg PO BID) and EA2 added P (200mg IV Q3 wks x 6 doses) each concurrent with chemoRT. Primary EP: 4-point reduction in Neoadjuvant Rectal Cancer (NAR) score with a one-sided α=0.10, 80% power. NAR compared by linear model controlling for clinical T4 at entry (Y/N). Secondary EPs: OS, DFS. p-values are two-sided. Results: From 10/2016-2/2018, 178 pts were randomized (88 CA, 90 EA1). From 8/2018-5/2019, 185 pts were randomized (95 CA, 90 EA2). Baseline characteristics were previously reported. Median follow-up is 3.50 yrs for the 1st comparison. Median follow-up is 3.15 yrs for the 2nd comparison. Updated primary and long-term secondary outcomes are in the table. Conclusions: With longer follow-up, addition of V to TNT provided no significant differences in the NAR score or 3yr outcomes. The addition of P to TNT was associated with a statistically significant improvement in 3yr OS, but not DFS. Correlative molecular analyses are ongoing. Support: U10CA180868, -180822; UG1-189867; U24-196067; AbbVie; Merck. Clinical trial information: NCT02921256 . [Table: see text]
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Affiliation(s)
| | - Greg Yothers
- University of Pittsburgh Department of Biostatistics, Pittsburgh, PA
| | | | - Theodore S. Hong
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Marcia McGory Russell
- David Geffen School of Medicine at UCLA; VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Y. Nancy You
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - William Parker
- McGill University Health Centre, Medical Physics Unit, Montreal, QC, Canada
| | | | - Peter C. Lucas
- UMPC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Marc J Gollub
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Madhuri Bajaj
- Illinois CancerCare, P.C. / Hartland NCORP, Peoria, IL
| | - Howard M. Gross
- Dayon NCI Community Oncology Research Program, Englewood, OH
| | | | - Jennifer Anne Dorth
- University Hospitals Seidman Cancer Center, and Case Western Reserve University Comprehensive Cancer Center LAPS, Cleveland, OH
| | | | - Norman Wolmark
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
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22
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Kharofa JR, Yothers G, Kachnic LA, Ajani J, Meyer JE, Augspurger ME, Okawara GS, Garg MK, Schefter TE, Swanson TA, Doncals DE, Kim H, Zaki BI, Narayan S, Lee RJ, Mamon HJ, Schwartz MA, Moughan J, Crane CH. Use of the Toxicity Index in Evaluating Adverse Events in Anal Cancer Trials: Analysis of RTOG 9811 and RTOG 0529. Am J Clin Oncol 2022; 45:534-536. [PMID: 36413683 PMCID: PMC9912479 DOI: 10.1097/coc.0000000000000955] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Novel toxicity metrics that account for all adverse event (AE) grades and the frequency of may enhance toxicity reporting in clinical trials. The Toxicity Index (TI) accounts for all AE grades and frequencies for categories of interest. We evaluate the feasibility of using the TI methodology in 2 prospective anal cancer trials and to evaluate whether more conformal radiation (using Intensity Modulated Radiation Therapy) results in improved toxicity as measured by the TI. Patients enrolled on NRG/RTOG 0529 or nonconformal RT enrolled on the 5-Fluorouracil/Mitomycin arm of NRG/RTOG 9811 were compared using the TI. Patients treated on NRG/RTOG 0529 had lower median TI compared with patients treated with nonconformal RT on NRG/RTOG 9811 for combined GI/GU/Heme/Derm events (3.935 vs 3.996, P=0.014). The TI methodology is a feasible method to assess all AEs of interest and may be useful as a composite metric for future efforts aimed at treatment de-escalation or escalation.
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Affiliation(s)
| | - Greg Yothers
- NRG Oncology Statistics and Data Management Center
| | | | | | | | | | - Gordon S Okawara
- Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON
| | | | | | | | | | - Hyun Kim
- Washington University School of Medicine, Saint Louis, MO
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23
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Kinslow CJ, DeStephano DM, Rohde CH, Kachnic LA, Cheng SK, Neugut AI, Horowitz DP. Risk of Anaplastic Large Cell Lymphoma Following Postmastectomy Implant Reconstruction in Women With Breast Cancer and Ductal Carcinoma in Situ. JAMA Netw Open 2022; 5:e2243396. [PMID: 36413370 PMCID: PMC9682428 DOI: 10.1001/jamanetworkopen.2022.43396] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This cohort study examines the risk of anaplastic large cell lymphoma (ALCL) following postmastectomy implant reconstruction among US women with breast cancer and ductal carcinoma in situ (DCIS).
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Affiliation(s)
- Connor J. Kinslow
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - David M. DeStephano
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Christine H. Rohde
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Lisa A. Kachnic
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Simon K. Cheng
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Alfred I. Neugut
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - David P. Horowitz
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
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24
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Yeung AR, Deshmukh S, Klopp AH, Gil KM, Wenzel L, Westin SN, Konski AA, Gaffney DK, Small W, Thompson JS, Doncals DE, Cantuaria GH, D'Souza DP, Chang A, Kundapur V, Mohan DS, Haas ML, Kim YB, Ferguson CL, Pugh SL, Kachnic LA, Bruner DW. Intensity-Modulated Radiation Therapy Reduces Patient-Reported Chronic Toxicity Compared With Conventional Pelvic Radiation Therapy: Updated Results of a Phase III Trial. J Clin Oncol 2022; 40:3115-3119. [PMID: 35960897 PMCID: PMC9851703 DOI: 10.1200/jco.21.02831] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 05/18/2022] [Accepted: 06/28/2022] [Indexed: 01/22/2023] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned coprimary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.The purpose of this update was to determine differences in patient-reported chronic toxicity and disease outcomes with intensity-modulated radiation therapy (IMRT) compared with conventional pelvic radiation. Patients with cervical and endometrial cancers who received postoperative pelvic radiation were randomly assigned to conventional radiation therapy (CRT) or IMRT. Toxicity and quality of life were assessed using Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events, Expanded Prostate Cancer Index Composite (EPIC) bowel and urinary domains, and Functional Assessment of Cancer Therapy-General. Between 2012 and 2015, 279 eligible patients were enrolled to the study with a median follow-up of 37.8 months. There were no differences in overall survival (P = .53), disease-free survival (P = .21), or locoregional failure (P = .81). One year after RT, patients in the CRT arm experienced more high-level diarrhea frequency (5.8% IMRT v 15.1% CRT, P = .042) and a greater number had to take antidiarrheal medication two or more times a day (1.2% IMRT v 8.6% CRT, P = .036). At 3 years, women in the CRT arm reported a decline in urinary function, whereas the IMRT arm continued to improve (mean change in EPIC urinary score = 0.5, standard deviation = 13.0, IMRT v -6.0, standard deviation = 14.3, CRT, P = .005). In conclusion, IMRT reduces patient-reported chronic GI and urinary toxicity with no difference in treatment efficacy at 3 years.
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Affiliation(s)
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | - Karen M. Gil
- Summa Akron City Hospital/Cooper Cancer Center, Akron, OH
| | - Lari Wenzel
- UC Irvine Health/Chao Family Comprehensive Cancer Center, Irvine, CA
| | | | - Andre A. Konski
- Chester County Hospital/University of Pennsylvania, West Chester, PA
| | - David K. Gaffney
- Huntsman Cancer Institute/University of Utah, Salt Lake City, UT
| | | | | | | | | | | | - Amy Chang
- Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong, China
| | | | | | | | - Yong Bae Kim
- Yonsei University Health System ACCRUALS UNDER MD Anderson Cancer Center, Yonsei-ro Seodaemun-gu, Seoul, South Korea
| | | | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - Lisa A. Kachnic
- NYP/Columbia University/Herbert Irving Comprehensive Cancer Center, New York, NY
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25
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Kiran RP, Kochhar GS, Kariv R, Rex DK, Sugita A, Rubin DT, Navaneethan U, Hull TL, Ko HM, Liu X, Kachnic LA, Strong S, Iacucci M, Bemelman W, Fleshner P, Safyan RA, Kotze PG, D'Hoore A, Faiz O, Lo S, Ashburn JH, Spinelli A, Bernstein CN, Kane SV, Cross RK, Schairer J, McCormick JT, Farraye FA, Chang S, Scherl EJ, Schwartz DA, Bruining DH, Philpott J, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sandborn WJ, Silverberg MS, Pardi DS, Church JM, Shen B. Management of pouch neoplasia: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2022; 7:871-893. [PMID: 35798022 DOI: 10.1016/s2468-1253(22)00039-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 02/07/2023]
Abstract
Surveillance pouchoscopy is recommended for patients with restorative proctocolectomy with ileal pouch-anal anastomosis in ulcerative colitis or familial adenomatous polyposis, with the surveillance interval depending on the risk of neoplasia. Neoplasia in patients with ileal pouches mainly have a glandular source and less often are of squamous cell origin. Various grades of neoplasia can occur in the prepouch ileum, pouch body, rectal cuff, anal transition zone, anus, or perianal skin. The main treatment modalities are endoscopic polypectomy, endoscopic ablation, endoscopic mucosal resection, endoscopic submucosal dissection, surgical local excision, surgical circumferential resection and re-anastomosis, and pouch excision. The choice of the treatment modality is determined by the grade, location, size, and features of neoplastic lesions, along with patients' risk of neoplasia and comorbidities, and local endoscopic and surgical expertise.
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Affiliation(s)
- Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Akira Sugita
- Department of Clinical Research and Department of inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital Yokohama, Japan
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Udayakumar Navaneethan
- IBD Center and IBD Interventional Unit, Center for Interventional Endoscopy, Orlando Health, Orlando, FL, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Huaibin Mabel Ko
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Xiuli Liu
- Department of Pathology and Immunology, Washington University, St Louis, MO, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Scott Strong
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, NIHR Birmingham Biomedical Research Centre, University Hospitals NHS Foundation Trust, University of Birmingham, UK
| | - Willem Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Philip Fleshner
- Division of Colorectal Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Rachael A Safyan
- Division of Hematology and Oncology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Paulo G Kotze
- IBD Outpatients Clinic, Catholic University of Paraná, Curitiba, Brazil
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Belgium
| | - Omar Faiz
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow and Department of Surgery and Cancer, Imperial College London, London, UK
| | - Simon Lo
- Pancreatic and Biliary Disease Program, Digestive Diseases, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Jean H Ashburn
- Department of Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University and IRCCS Humanitas Research Hospital, Division Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Charles N Bernstein
- University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre, Winnipeg, MB, Canada
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, MD, USA
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Shannon Chang
- Inflammatory Bowel Disease Center, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Ellen J Scherl
- Jill Roberts Center for IBD, Gastroenterology and Hepatology, Weill Cornell Medicine and NewYork Presbyterian Hospital, New York, NY, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - William J Sandborn
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Mark S Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, ON, Canada
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - James M Church
- Division of Colorectal Surgery, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA.
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26
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Kinslow CJ, Kim A, Sanchez GI, Cheng SK, Kachnic LA, Neugut AI, Horowitz DP. Incidence of Anaplastic Large-Cell Lymphoma of the Breast in the US, 2000 to 2018. JAMA Oncol 2022; 8:1354-1356. [PMID: 35862042 DOI: 10.1001/jamaoncol.2022.2624] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Connor J Kinslow
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Arreum Kim
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Gloria I Sanchez
- Group of Infection and Cancer, School of Medicine, University of Antioquia, Medellín, Colombia
| | - Simon K Cheng
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Alfred I Neugut
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - David P Horowitz
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
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27
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Park J, Venkatesulu BP, Kujundzic K, Katsoulakis E, Solanki AA, Puckett LL, Kapoor R, Chapman CH, Hagan M, Kelly MD, Palta J, Ashman JB, Jacqmin D, Kachnic LA, Minsky BD, Olsen J, Raldow AC, Wo JY, Dawes S, Wilson E, Kudner R, Das P. Consensus Quality Measures and Dose Constraints for Rectal Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology (ASTRO) Expert Panel. Pract Radiat Oncol 2022; 12:424-436. [PMID: 35907764 DOI: 10.1016/j.prro.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Ensuring high quality, evidence-based radiation therapy for patients with cancer is of the upmost importance. To address this need, the Veterans Affairs (VA) Radiation Oncology Program partnered with the American Society for Radiation Oncology and established the VA Radiation Oncology Quality Surveillance program. As part of this ongoing effort to provide the highest quality of care for patients with rectal cancer, a blue-ribbon panel comprised of rectal cancer experts was formed to develop clinical quality measures. METHODS AND MATERIALS The Rectal Cancer Blue Ribbon panel developed quality, surveillance, and aspirational measures for (a) initial consultation and workup, (b) simulation, treatment planning, and treatment, and (c) follow-up. Twenty-two rectal cancer specific measures were developed (19 quality, 1 aspirational, and 2 surveillance). In addition, dose-volume histogram constraints for conventional and hypofractionated radiation therapy were created. CONCLUSIONS The quality measures and dose-volume histogram for rectal cancer serves as a guideline to assess the quality of care for patients with rectal cancer receiving radiation therapy. These quality measures will be used for quality surveillance for veterans receiving care both inside and outside the VA system to improve the quality of care for these patients.
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Affiliation(s)
- John Park
- Department of Radiation Oncology, Kansas City VA Medical Center, Kansas City, Missouri; Department of Radiology, University of Missouri Kansas City School of Medicine, Kansas City, Missouri.
| | - Bhanu Prasad Venkatesulu
- Department of Radiation Oncology, Strich School of Medicine, Loyola University, Chicago, Illinois
| | | | - Evangelia Katsoulakis
- Department of Radiation Oncology, James A. Haley Veterans Affairs Healthcare System, Tampa, Florida
| | - Abhishek A Solanki
- Department of Radiation Oncology, Strich School of Medicine, Loyola University, Chicago, Illinois; Department of Radiation Oncology, Edward Hines, Jr. VA Hospital, Chicago, Illinois
| | - Lindsay L Puckett
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Radiation Oncology, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
| | - Rishabh Kapoor
- Department of Radiation Oncology, Virginia Commonwealth University School of Medicine, Richmond, Virginia; Department of Radiation Oncology, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
| | - Christina H Chapman
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, Michigan; Department of Radiation Oncology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Michael Hagan
- Department of Radiation Oncology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maria D Kelly
- VHA National Radiation Oncology Program, Richmond, Virginia
| | - Jatinder Palta
- Department of Radiation Oncology, Virginia Commonwealth University School of Medicine, Richmond, Virginia; VHA National Radiation Oncology Program, Richmond, Virginia
| | | | - Dustin Jacqmin
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey Olsen
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Ann C Raldow
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Samantha Dawes
- American Society for Radiation Oncology, Arlington, Virginia
| | - Emily Wilson
- American Society for Radiation Oncology, Arlington, Virginia
| | - Randi Kudner
- American Society for Radiation Oncology, Arlington, Virginia
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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28
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Huh WK, Pugh SL, Walker JL, Pennington K, Jewell EL, Havrilesky LJ, Carter J, Muller C, Drapkin R, Lankes HA, Demora L, Kachnic LA. NRG-CC008: A nonrandomized prospective clinical trial comparing the non-inferiority of salpingectomy to salpingo-oophorectomy to reduce the risk of ovarian cancer among BRCA1 carriers [SOROCk]. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.tps10615] [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
TPS10615 Background: Studies of ovarian cancer screening in the general population have not demonstrated a reduction in ovarian cancer mortality. High-grade pelvic serous carcinomas (HGSCs) have traditionally been thought to originate from the ovarian surface epithelium. However, more recent data strongly suggests that most HGSCs originate from precursor lesions found in the distal fallopian tube. Serous tubal intra-epithelial carcinoma (STIC) lesions are found in association with HGSCs in 50-60% of cases and other early serous precursor lesions can be identified in an additional 25% of cases. The Society of Gynecologic Oncology has recently issued recommendations that salpingectomy can be considered at the completion of childbearing in indiviuals at increased genetic risk of ovarian cancer who do not agree to salpingo-oophorectomy. They also indicated that approximately 30% of BRCA1 mutation carriers choose not to remove their ovaries, and the mean age at RRSO for those who do is in the late 40s, much later than recommended age per guidelines. The purpose of this study is to compare risk-reducing approaches in high-risk women with deleterious germline BRCA1mutations; specifically, to demonstrate the non-inferiority of bilateral salpingectomy compared to bilateral salpingo-oophorectomy to reduce the incidence of ovarian cancer among deleterious germline BRCA1mutation carriers. Methods: This is a non-randomized prospective trial to determine if bilateral salpingectomy is non-inferior to bilateral salpingo-oophorectomy in terms ovarian, primary peritoneal, and fallopian tube cancer risk among gBRCA1m carriers between 35 and 50 years old. Individuals choose the treatment they want to receive in collaboration with their physician(s). The primary endpoint is the time to development of incident HGSC, specifically ovarian, primary peritoneal, or fallopian tube cancers. Secondary endpoints include measurement of health-related quality of life, estrogen deprivation symptoms, sexual function, menopausal symptoms, cancer distress, Medical Decision Making, and adverse events. Results: As of 1/31/2022, 116 individuals have been enrolled into this trial. A recent amendment was put forward to allow the following individuals to also participate in this trial: 1) Individuals who are receiving hormonal therapy for maintenance therapy (eg, tamoxifen, AIs, etc), 2) Individuals with a history of any prior cancer and have completed chemotherapy, at least 30 days ago, and 3) Individuals who are considering Assisted Reproductive Technologies (eg, IVF). Furthermore, there is ongoing consideration of allowing general Ob/Gyn providers to recruit patients to this trial and perform procedures, with proper pathology training and sign off at their hospitals. NCI grant UG1CA189867. Clinical trial information: NCT04251052.
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Affiliation(s)
- Warner King Huh
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - Joan L. Walker
- The University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | | - Elizabeth Lin Jewell
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Laura J Havrilesky
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Jeanne Carter
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Heather A. Lankes
- NRG Operations Center - Philadelphia East Four Penn Center, Philadelphia, PA
| | - Lyudmila Demora
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
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Schoen RE, Bandos H, Corley D, Dueker J, Yothers G, Bai J, Huh WK, Bauman JE, Walker JL, Bruner D, Kachnic LA. Five- or 10-year colonoscopy for 1-2 non-advanced adenomatous polyps (FORTE) NRG-CC005 study: A randomized phase III non-inferiority trial comparing colorectal cancer incidence in participants with 1-2 non-advanced adenomas randomized to a 5- and 10-year surveillance colonoscopy exam schedule versus a 10-year surveillance colonoscopy exam schedule. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.tps3631] [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
TPS3631 Background: Adenomatous polyps are the acknowledged precursors of colorectal cancer (CRC). Identification and removal of adenomas is the mechanism by which screening is effective in reducing CRC incidence and mortality. Patients with 1-2 non-advanced adenomas ( < 1 cm with neither villous components nor high grade dysplasia) are recommended to return at a timing ranging from 5-10 yrs. However, evidence for the benefit, optimal timing, and recommended frequency of surveillance colonoscopy is not available. A randomized, clinical trial to demonstrate the difference in results between 5- or 10-yr surveillance for participants with non-advanced adenoma can guide clinical practice. Methods: NRG-CC005/FORTE is a prospective, randomized, non-blinded, Phase III, non-inferiority clinical trial comparing CRC incidence in participants randomized to recommendation for a 5- and 10-yr vs. a 10-yr only surveillance colonoscopy exam schedule. Other pre-defined exploratory endpoints include incidence of advanced adenomas, CRC mortality, and incidence of stage III-IV CRCs. Stratification factors include age, gender, and time from qualifying colonoscopy to randomization. Participants ≥50 and < 70 yrs of age at the time of randomization with a first-time diagnosis of 1-2 non-advanced tubular adenomas from the qualifying colonoscopy within 4 yrs prior to randomization will be eligible. Participants with a clinical diagnosis of a significant genetic risk for CRC or with a family history of CRC diagnosed at ≤60 yrs in a first degree relative or in two first degree relatives diagnosed at any age are ineligible. Other ineligibility criteria include prior history of CRC or colorectal adenomas, a hyperplastic polyp measuring ≥1 cm or traditional serrated adenomas, or life expectancy < 10 yrs due to comorbid conditions. Collection of blood, stool, and tissue samples is planned. Statistics: The primary endpoint for the trial is CRC incidence. The trial is focused on CRCs diagnosed between year 5 and year 10. By incorporating a window of +/- 1 yr to allow for somewhat earlier and later procedures, as typically occurs in clinical medicine, the primary endpoint will include incident cancers identified in years 4 through 11. A crude 4- to 11-yr incidence rate of 0.387% is assumed for the 5- and 10-yr schedule arm. The study is powered at 90% to detect a non-inferiority margin difference of 0.387% at alpha 5% in CRC incidence rate between two schedules. 9,500 participants are to be enrolled. Support: U10CA180868, -180822, UG1CA189867, U24CA196067 Clinical trial information: NCT05080673.
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Affiliation(s)
| | - Hanna Bandos
- NSABP and The University of Pittsburgh, Pittsburgh, PA
| | - Douglas Corley
- Kaiser Permanente, Northern California Division of Research, Oakland, CA
| | - Jeff Dueker
- University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA
| | - Greg Yothers
- The Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - Jinbing Bai
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Warner King Huh
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Joan L. Walker
- The University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Deborah Bruner
- Winship Cancer Institute at Emory University, Atlanta, GA
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Tchelebi LT, Eng C, Messick CA, Hong TS, Ludmir EB, Kachnic LA, Zaorsky NG. Current treatment and future directions in the management of anal cancer. CA Cancer J Clin 2022; 72:183-195. [PMID: 34847242 DOI: 10.3322/caac.21712] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/15/2021] [Accepted: 10/18/2021] [Indexed: 12/18/2022] Open
Abstract
Although rare, the rate of squamous cell carcinoma of the anus (SCCA) is rising globally. Most patients present with nonmetastatic disease and are curable with appropriate treatment, which has evolved significantly over the last several decades. Before the 1970s, SCCA was managed with radical surgery, resulting in a permanent colostomy. Researchers found that preoperative treatment with chemotherapy and concurrent radiation could achieve a pathologic complete response. After this observation, definitive therapy shifted from radical surgery to sphincter-preserving chemoradiation. Investigations into the necessity of chemotherapy and the optimal regimen found that chemotherapy with mitomycin-C and 5-fluorouracil is required for cure. Further studies evaluating the addition of induction or maintenance chemotherapy, monoclonal antibody therapy, or higher radiation doses have demonstrated no significant benefit to disease control. Advanced radiation delivery with intensity-modulated radiotherapy techniques is now considered the standard of care because of its prospectively determined, favorable acute toxicity profile compared with 3-dimensional conformal radiation. It is important to note that chemoradiation treatment response may be slow (up to 26 weeks) and should be assessed through serial clinical examinations. Today, surgical management of SCCA is reserved only for the lowest risk, early stage tumors or for recurrent/persistent disease. Current studies are evaluating radiation dose de-escalation in early stage disease and radiation dose escalation and the addition of immune checkpoint inhibitors in locally advanced cancers. In reviewing how and why modern-day treatment of SCCA was established, the objective of this report is to reenforce adherence to current treatment paradigms to assure the best possible outcomes for patients.
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Affiliation(s)
- Leila T Tchelebi
- Department of Radiation Medicine, Zucker School of Medicine, Hempstead, New York
- Department of Radiation Medicine, Northwell Health Cancer Institute, Mount Kisco, New York
| | - Cathy Eng
- Department of Hematology and Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Craig A Messick
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve School of Medicine, Cleveland, Ohio
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
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Barton DL, Pugh SL, Ganz PA, Plaxe SC, Koontz BF, Carter J, Greyz-Yusupov N, Page SJ, Rowland KM, Balcueva EP, Nabeel S, Basil JB, Hill ML, Muller CY, Bell MC, Deshmukh S, Kachnic LA. Randomized Controlled Phase II Evaluation of Two Dose Levels of Bupropion Versus Placebo for Sexual Desire in Female Cancer Survivors: NRG-CC004. J Clin Oncol 2022; 40:324-334. [PMID: 34882500 PMCID: PMC8797544 DOI: 10.1200/jco.21.01473] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Because of the negative impact of cancer treatment on female sexual function, effective treatments are warranted. The purpose of this multisite study was to evaluate the ability of two dose levels of extended-release bupropion, a dopaminergic agent, to improve sexual desire more than placebo at 9 weeks, measured by the desire subscale of the Female Sexual Function Index (FSFI), and to evaluate associated toxicities. METHODS Postmenopausal women diagnosed with breast or gynecologic cancer and low baseline FSFI desire scores (< 3.3), who had completed definitive cancer therapy, were eligible. Women were randomly assigned to receive 150 mg or 300 mg once daily of extended-release bupropion or a matching placebo. t-tests were performed on the FSFI desire subscale to evaluate whether there was a significantly greater change from baseline to 9 weeks between placebo and each bupropion arm as the primary end point. Sixty-two patients per arm provided 80% power using a one-sided t-test. RESULTS Two hundred thirty women were randomly assigned from 72 institutions through the NRG Oncology NCORP network. At 9 weeks, there were no statistically significant differences in change of the desire subscale scores between groups; participants in all three arms reported improvement. The mean changes for each arm were placebo 0.62 (standard deviation [SD] = 1.18), 150-mg once daily bupropion 0.64 (SD = 0.95), and 300-mg once daily bupropion 0.60 (SD = 0.89). Total and subscale scores on the FSFI were low throughout the study, indicating dysfunction in all groups. CONCLUSION Bupropion was not more effective than placebo in improving the desire subscale of the FSFI. Subscale and total scores of the FSFI demonstrated dysfunction throughout the 9 weeks of the study. More research is needed to support sexual function in female cancer survivors.
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Affiliation(s)
- Debra L. Barton
- University of Michigan School of Nursing, Ann Arbor, MI,Debra L. Barton, RN, PhD, University of Michigan School of Nursing, 400 North Ingalls Building, Ann Arbor, MI 48109-5482; e-mail:
| | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA
| | | | | | | | - Jeanne Carter
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Ernie P. Balcueva
- Ascension Michigan St Marys Hospital, Saginaw, MI accrual under Michigan Cancer Research Consortium NCORP
| | - Sobia Nabeel
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jack B. Basil
- Bethesda North Hospital, Cincinnati, OH accrual under Catholic Health Initiatives NCORP
| | - Matthew L. Hill
- Medical Oncology and Hematology Associates-Des Moines, Des Moines, IA accrual under Iowa-Wide Oncology Research Coalition NCORP
| | - Carolyn Y. Muller
- University of New Mexico Cancer Center, Albuquerque, NM accrual under New Mexico Minority Underserved NCORP
| | - Maria C. Bell
- Sanford Health, Sioux Falls, SD accrual under Sanford NCI Community Oncology Research Program of the North Central Plains
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA
| | - Lisa A. Kachnic
- NYP-Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center, New York, NY
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Safran HP, Winter K, Ilson DH, Wigle D, DiPetrillo T, Haddock MG, Hong TS, Leichman LP, Rajdev L, Resnick M, Kachnic LA, Seaward S, Mamon H, Diaz Pardo DA, Anderson CM, Shen X, Sharma AK, Katz AW, Salo J, Leonard KL, Moughan J, Crane CH. Trastuzumab with trimodality treatment for oesophageal adenocarcinoma with HER2 overexpression (NRG Oncology/RTOG 1010): a multicentre, randomised, phase 3 trial. Lancet Oncol 2022; 23:259-269. [PMID: 35038433 PMCID: PMC8903071 DOI: 10.1016/s1470-2045(21)00718-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/06/2021] [Accepted: 12/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Trastuzumab is a monoclonal antibody against HER2 (also known as ERBB2). The primary objective of the NRG Oncology/RTOG-1010 trial was to establish whether trastuzumab improves disease-free survival when combined with trimodality treatment (paclitaxel plus carboplatin and radiotherapy, followed by surgery) for patients with untreated HER2-overexpressing oesophageal adenocarcinoma. METHODS NRG Oncology/RTOG-1010 was an open label, randomised, phase 3 trial for which patients were accrued from 111 NRG-affiliated institutions in the USA. Eligible patients were adults (aged ≥18 years) with newly diagnosed pathologically confirmed oesophageal adenocarcinoma, American Joint Committee on Cancer 7th edition T1N1-2 or T2-3N0-2 stage disease, and a Zubrod performance status of 0-2. Patients were stratified by adenopathy (no vs yes [coeliac absent] vs yes [coeliac present ≤2 cm]) and randomly assigned (1:1) to receive weekly intravenous paclitaxel (50 mg/m2 intravenously over 1 h) and carboplatin (area under the curve 2, intravenously over 30-60 min) for 6 weeks with radiotherapy 50·4 Gy in 28 fractions (chemoradiotherapy) followed by surgery, with or without intravenous trastuzumab (4 mg/kg in week one, 2 mg/kg per week for 5 weeks during chemoradiotherapy, 6 mg/kg once presurgery, and 6 mg/kg every 3 weeks for 13 treatments starting 21-56 days after surgery). The primary endpoint, disease-free survival, was defined as the time from randomisation to death or first of locoregional disease persistence or recurrence, distant metastases, or second primary malignancy. Analyses were done by modified intention to treat. This study is registered with Clinicaltrials.gov, NCT01196390; it is now closed and in follow-up. FINDINGS 606 patients were entered for HER2 assessment from Dec 30, 2010 to Nov 10, 2015, and 203 eligible patients who were HER2-positive were enrolled and randomly assigned to chemoradiotherapy plus trastuzumab (n=102) or chemoradiotherapy alone (n=101). Median duration of follow-up was 2·8 years (IQR 1·4-5·7). Median disease-free survival was 19·6 months (95% CI 13·5-26·2) with chemoradiotherapy plus trastuzumab compared with 14·2 months (10·5-23·0) for chemoradiotherapy alone (hazard ratio 0·99 [95% CI 0·71-1·39], log-rank p=0·97). Grade 3 treatment-related adverse events occurred in 41 (43%) of 95 patients in the chemoradiotherapy plus trastuzumab group versus 52 (54%) of 96 in the chemoradiotherapy group and grade 4 events occurred in 20 (21%) versus 21 (22%). The most common grade 3 or worse treatment-related adverse events for both groups were haematological (53 [56%] of 95 patients in the chemoradiotherapy plus trastuzumab group vs 55 [57%] of 96 patients in the chemotherapy group) or gastrointestinal disorders (28 [29%] vs 20 [21 %]). 34 (36%) of 95 patients in the chemoradiotherapy plus trastuzumab group and 27 (28%) of 96 patients in the chemoradiotherapy only group had treatment-related serious adverse events. There were eight treatment-related deaths: five (5%) of 95 patients in the chemoradiotherapy plus trastuzumab group (bronchopleural fistula, oesophageal anastomotic leak, lung infection, sudden death, and death not otherwise specified), and three (3%) of 96 in the chemoradiotherapy group (two multiorgan failure and one sepsis). INTERPRETATION The addition of trastuzumab to neoadjuvant chemoradiotherapy for HER2-overexpressing oesophageal cancer was not effective. Trastuzumab did not lead to increased toxicities, suggesting that future studies combining it with or using other agents targeting HER2 in oesophageal cancer are warranted. FUNDING National Cancer Institute and Genentech.
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Wong W, Jamison JK, May MS, Michel A, Lee T, Manrique D, Raufi A, Pan SM, Safyan RA, Horowitz DP, Schrope B, Kluger M, Kachnic LA, Hu J, Bates SE, Chabot JA, Manji GA. Neoadjuvant gemcitabine, docetaxel, and capecitabine results in comparable surgical outcomes to modified FOLFIRINOX in patients with pancreatic ductal adenocarcinoma who also receive radiation: A single institution experience. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.4_suppl.565] [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
565 Background: Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis with a minority of patients (pts) eligible for curative resection. Currently, systemic treatment options for down-staging pts with borderline resectable or locally advanced PDAC is extrapolated from the metastatic setting and modified FOLFIRINOX (FFX) +/- radiation (RT) is the most widely used regimen. Herein, we report the outcomes of combination gemcitabine, docetaxel, and capecitabine (GTX) +RT as compared to FFX +RT in the neoadjuvant (NA) setting via a single institution retrospective cohort review. Methods: We retrospectively reviewed the outcomes of pts with PDAC who underwent surgical resection at Columbia University Irving Medical Center (CUIMC) between 2011-2020. We evaluated demographics, treatment, clinical, surgical, and pathological outcomes. Statistical analysis includes Kaplan-Meier analysis and paired t-tests. Results: We reviewed 717 pts who underwent surgical resection at CUIMC of which 227 pts were confirmed to have received NA chemotherapy. Of those 227 patients, 133 pts also received RT. In total, 39 pts received GTX+RT and 42 pts received FFX+RT. Median age at diagnosis of pts who received NA GTX+RT or FFX+RT was 65 and 63 years, respectively. All pts were AJCC stage III at diagnosis and ECOG 0 or 1. There was a significantly greater percentage of pts who achieved R0 resection after GTX+RT as compared to FFX+RT, 35 (89.7%) vs 29 (69.0%), respectively (p=0.022). Significantly more pts achieved N0 lymph node status after GTX+RT as compared to FFX+RT, 29 (74.4%) vs 22 (52.4%), respectively (p=0.041). No statistically significant difference was detected in recurrence-free survival (RFS) or median overall survival (mOS) in pts who received GTX+RT and achieved R0 resection as compared to FFX+RT. See Table for summary. Conclusions: GTX appears to be a viable and active NA regimen in Stage III PDAC. In our small cohort study, more patients who received GTX+RT achieved R0 resection and N0 status as compared to FFX+RT. No difference in survival was detected but this may be due to inadequate power or choice of subsequent therapies. Larger prospective studies evaluating GTX+RT as an alternative treatment in the NA setting are warranted.[Table: see text]
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Affiliation(s)
- Winston Wong
- Columbia University Medical Center, New York, NY
| | | | | | - Alissa Michel
- Columbia University Irving Medical Center, New York, NY
| | - Tristan Lee
- Columbia University Irving Medical Center, New York, NY
| | | | | | - Samuel M Pan
- Columbia University Irving Medical Center, New York, NY
| | | | - David Paul Horowitz
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - Beth Schrope
- Columbia University Irving Medical Center, New York, NY
| | | | | | - Jianhua Hu
- Columbia University Medical Center, New York, NY
| | - Susan Elaine Bates
- Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY
| | | | - Gulam Abbas Manji
- Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY
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Kachnic LA, Winter K, Myerson RJ, Goodyear MD, Abitbol AA, Streeter OE, Augspurger ME, Schefter TE, Katz AW, Fisher BJ, Henke LE, Narayan S, Crane CH. Long-Term Outcomes of NRG Oncology/RTOG 0529: A Phase 2 Evaluation of Dose-Painted Intensity Modulated Radiation Therapy in Combination With 5-Fluorouracil and Mitomycin-C for the Reduction of Acute Morbidity in Anal Canal Cancer. Int J Radiat Oncol Biol Phys 2022; 112:146-157. [PMID: 34400269 PMCID: PMC8688291 DOI: 10.1016/j.ijrobp.2021.08.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [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: 04/19/2021] [Revised: 07/28/2021] [Accepted: 08/05/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE A multi-institutional phase 2 trial assessed long-term outcomes of dose-painted intensity modulated radiation therapy (IMRT) with 5-fluorouracil (5FU) and mitomycin-C (MMC) for anal canal cancer. METHODS AND MATERIALS T2-4N0-3M0 anal cancers received 5FU (1000 mg/m2/d, 96-hour infusion) and MMC (10 mg/m2 bolus) on days 1 and 29 of dose-painted IMRT prescribed as follows: T2N0 = 42 Gy elective nodal and 50.4 Gy anal tumor planning target volumes, 28 fractions; T3-4N0-3 = 45Gy elective nodal, 50.4 Gy ≤3 cm and 54 Gy >3cm metastatic nodal and 54 Gy anal tumor planning target volumes, 30 fractions. Local-regional failures, distant metastases, and colostomy failures were assessed using the cumulative incidence method, and disease-free survival, overall survival, and colostomy-free survival were assessed using the Kaplan-Meier method. Late effects were scored using National Cancer Institute-Common Terminology Criteria for Adverse Events v3. RESULTS Of 52 patients, 54% were stage II, 25% were stage IIIA, and 21% were stage IIIB. Median follow-up was 7.9 years (min-max, 0.02-9.2 years). Local-regional failure, colostomy failures, distant metastases, overall survival, disease-free survival, and colostomy-free survival at 5 years are 16% (95% confidence interval [CI], 7%-27%), 10% (95% CI, 4%-20%), 16% (95% CI, 7%-27%), 76% (95% CI, 61%-86%), 70% (95% CI, 56%-81%), and 74% (95% CI, 59%-84%); and at 8 years they are 16% (95% CI, 7%-27%), 12% (95% CI, 5%-23%), 22% (95% CI, 12%-34%), 68% (95% CI, 53%-79%), 62% (95% CI, 47%-74%) and 66% (95% CI, 51%-77%), respectively. Eight patients experienced local-regional failure, with 5 patients having persistent disease at 12 weeks. No isolated nodal failures occurred in the microscopic elective nodal volumes. Six patients required colostomy-5 for local-regional salvage and 1 for a temporary ostomy for anorectal dysfunction. Rates of late adverse events included: 28 patients (55%) with grade 2, 8 patients (16%) with grade 3, 0 patients with grade 4, and 2 patients (4%) with grade 5 events (sinus bradycardia and myelodysplasia, possibly owing to chemotherapy). Only 11 patients reported grade 1 to 3 sexual dysfunction. CONCLUSIONS Dose-painted IMRT with 5FU/MMC for the treatment of anal canal cancer yields comparable long-term efficacy as conventional radiation cohorts. Enhanced normal tissue protection lowered rates of grade 3 and higher late effects without compromising pelvic tumor control.
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Abraham CD, Pugh SL, Bovi JA, Gondi V, Mehta MP, Benzinger T, Owen CJ, Lo SS, Kundapur V, Brown PD, Sun AY, Howard SP, DeNittis AS, Robinson CG, Kachnic LA. Association of Pretreatment Hippocampal Volume With Neurocognitive Function in Patients Treated With Hippocampal Avoidance Whole Brain Radiation Therapy for Brain Metastases: Secondary Analysis of NRG Oncology/RTOG 0933. Adv Radiat Oncol 2021; 7:100859. [PMID: 36420209 PMCID: PMC9677217 DOI: 10.1016/j.adro.2021.100859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 06/22/2020] [Accepted: 11/05/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose Hippocampal volume (HV) is an established predicting factor for neurocognitive function (NCF) in neurodegenerative disease. Whether the same phenomenon exists with hippocampal-avoidant whole brain radiation therapy is not known; therefore, we assessed the association of baseline HV with NCF among patients enrolled on RTOG 0933. Methods and Materials Hippocampal volume and total brain volume were calculated from the radiation therapy plan. Hippocampal volume was correlated with baseline and 4-month NCF scores (Hopkins Verbal Learning Test-Revised [HVLT-R] Total Recall [TR], Immediate Recognition, and Delayed Recall [DR]) using Pearson correlation. Deterioration in NCF was defined per the primary endpoint of RTOG 0933(mean 4-month relative decline in HVLT-R DR). Comparisons between patients with deteriorated and nondeteriorated NCF were made using the Wilcoxon test. Results Forty-two patients were evaluable. The median age was 56.5 years (range, 28-83 years), and 81% had a class II recursive partitioning analysis. The median total, right, and left HVs were 5.4 cm3 (range, 1.9-7.4 cm3), 2.8 cm3 (range, 0.9-4.0 cm3), and 2.7 cm3 (range, 1.0-3.7 cm3), respectively. The median total brain volume was 1343 cm3 (range, 1120.5-1738.8 cm3). For all measures of corrected HV, increasing HV was associated with higher baseline HVLT-R TR and DR scores (ρ: range, 0.35-0.40; P-value range, .009-.024) and 4-month TR and DR scores (ρ: range, 0.29-0.40; P-value range, .009-.04), with the exception of right HV and 4-month DR scores (ρ: 0.29; P = .059). There was no significant association between HV and NCF change between baseline and 4 months. Fourteen patients (33.3%) developed NCF deterioration per the primary endpoint of RTOG 0933. There was no significant difference in HV between patients with deteriorated and nondeteriorated NCF, although in all instances, patients with deteriorated NCF had numerically lower HV. Conclusions Larger HV was positively associated with improved performance on baseline and 4-month HVLT-R TR and DR scores in patients with brain metastases undergoing hippocampal-avoidant whole brain radiation therapy but was not associated with a change in NCF.
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Affiliation(s)
- Christopher D. Abraham
- Washington University School of Medicine, Saint Louis, Missouri,Barnes-Jewish Hospital, Saint Louis, Missouri,Corresponding author: Christopher D. Abraham, MD
| | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Joseph A. Bovi
- Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Vinai Gondi
- Northwestern Medicine Cancer, Warrenville, Illinois
| | | | | | | | - Simon S. Lo
- University of Washington Medical Center, Seattle, Washington
| | | | | | - Alexander Y. Sun
- University Health Network–Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Steven P. Howard
- University of Wisconsin Hospital and Clinics, Madison, Wisconsin
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Shuryak I, Kachnic LA, Brenner DJ. In Reply to Welsh et al. Int J Radiat Oncol Biol Phys 2021; 111:576-577. [PMID: 34473976 PMCID: PMC8403552 DOI: 10.1016/j.ijrobp.2021.05.121] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Igor Shuryak
- Department of Radiation Oncology, Center for Radiological Research, Columbia University Irving Medical Center, New York, New York
| | - Lisa A Kachnic
- Department of Radiation Oncology, Center for Radiological Research, Columbia University Irving Medical Center, New York, New York
| | - David J Brenner
- Department of Radiation Oncology, Center for Radiological Research, Columbia University Irving Medical Center, New York, New York
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Shuryak I, Kachnic LA, Brenner DJ. Lung Cancer and Heart Disease Risks Associated With Low-Dose Pulmonary Radiotherapy to COVID-19 Patients With Different Background Risks. Int J Radiat Oncol Biol Phys 2021; 111:233-239. [PMID: 33930480 PMCID: PMC8078051 DOI: 10.1016/j.ijrobp.2021.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/31/2021] [Accepted: 04/14/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE The respiratory disease COVID-19 reached global pandemic status in 2020. Excessive inflammation is believed to result in the most severe symptoms and death from this disease. Because treatment options for patients with severe COVID-19 related pulmonary symptoms remain limited, whole-lung low-dose radiation therapy is being evaluated as an anti-inflammatory modality. However, there is concern about the long-term risks associated with low-dose pulmonary irradiation. To help quantify the benefit-risk balance of low-dose radiation therapy for COVID-19, we estimated radiation-induced lifetime risks of both lung cancer and heart disease (major coronary events) for patients of different sexes, treated at ages 50 to 85, with and without other relevant risk factors (cigarette smoking and baseline heart disease risk). METHODS AND MATERIALS These estimates were generated by combining state-of-the-art radiation risk models for lung cancer and for heart disease together with background lung cancer and heart disease risks and age/sex-dependent survival probabilities for the U.S. POPULATION RESULTS Estimated absolute radiation-induced risks were generally higher for lung cancer compared with major coronary events. The highest estimated lifetime radiation-induced lung cancer risks were approximately 6% for female smokers treated between ages 50 and 60. The highest estimated radiation-induced heart disease risks were approximately 3% for males or females with high heart disease risk factors and treated between ages 50 and 60. CONCLUSIONS The estimated summed lifetime risk of lung cancer and major coronary events reached up to 9% in patients with high baseline risk factors. Predicted lung cancer and heart disease risks were lowest in older nonsmoking patients and patients with few cardiac risk factors. These long-term risk estimates, along with consideration of possible acute reactions, should be useful in assessing the benefit-risk balance for low-dose radiation therapy to treat severe COVID-19 pulmonary symptoms, and suggest that background risk factors, particularly smoking, should be taken into account in such assessments.
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Affiliation(s)
- Igor Shuryak
- Center for Radiological Research, Department of Radiation Oncology; Department of Radiation Oncology, Columbia University Irving Medical Center, New York.
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York
| | - David J Brenner
- Center for Radiological Research, Department of Radiation Oncology; Department of Radiation Oncology, Columbia University Irving Medical Center, New York
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38
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Rahma OE, Yothers G, Hong TS, Russell MM, You YN, Parker W, Jacobs SA, Colangelo LH, Lucas PC, Gollub MJ, Hall WA, Kachnic LA, Vijayvergia N, O'Rourke MA, Faller BA, Valicenti RK, Schefter TE, Moxley KM, Kainthla R, Stella PJ, Sigurdson E, Wolmark N, George TJ. Use of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: Initial Results From the Pembrolizumab Arm of a Phase 2 Randomized Clinical Trial. JAMA Oncol 2021; 7:1225-1230. [PMID: 34196693 DOI: 10.1001/jamaoncol.2021.1683] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Total neoadjuvant therapy (TNT) is often used to downstage locally advanced rectal cancer (LARC) and decrease locoregional relapse; however, more than one-third of patients develop recurrent metastatic disease. As such, novel combinations are needed. Objective To assess whether the addition of pembrolizumab during and after neoadjuvant chemoradiotherapy can lead to an improvement in the neoadjuvant rectal (NAR) score compared with treatment with FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) and chemoradiotherapy alone. Design, Setting, and Participants In this open-label, phase 2, randomized clinical trial (NRG-GI002), patients in academic and private practice settings were enrolled. Patients with stage II/III LARC with distal location (cT3-4 ≤ 5 cm from anal verge, any N), with bulky disease (any cT4 or tumor within 3 mm of mesorectal fascia), at high risk for metastatic disease (cN2), and/or who were not candidates for sphincter-sparing surgery (SSS) were stratified based on clinical tumor and nodal stages. Trial accrual opened on August 1, 2018, and ended on May 31, 2019. This intent-to-treat analysis is based on data as of August 2020. Interventions Patients were randomized (1:1) to neoadjuvant FOLFOX for 4 months and then underwent chemoradiotherapy (capecitabine with 50.4 Gy) with or without intravenous pembrolizumab administered at a dosage of 200 mg every 3 weeks for up to 6 doses before surgery. Main Outcomes and Measures The primary end point was the NAR score. Secondary end points included pathologic complete response (pCR) rate, SSS, disease-free survival, and overall survival. This report focuses on end points available after definitive surgery (NAR score, pCR, SSS, clinical complete response rate, margin involvement, and safety). Results A total of 185 patients (126 [68.1%] male; mean [SD] age, 55.7 [11.1] years) were randomized to the control arm (CA) (n = 95) or the pembrolizumab arm (PA) (n = 90). Of these patients, 137 were evaluable for NAR score (68 CA patients and 69 PA patients). The mean (SD) NAR score was 11.53 (12.43) for the PA patients (95% CI, 8.54-14.51) vs 14.08 (13.82) for the CA patients (95% CI, 10.74-17.43) (P = .26). The pCR rate was 31.9% in the PA vs 29.4% in the CA (P = .75). The clinical complete response rate was 13.9% in the PA vs 13.6% in the CA (P = .95). The percentage of patients who underwent SSS was 59.4% in the PA vs 71.0% in the CA (P = .15). Grade 3 to 4 adverse events were slightly increased in the PA (48.2%) vs the CA (37.3%) during chemoradiotherapy. Two deaths occurred during FOLFOX: sepsis (CA) and pneumonia (PA). No differences in radiotherapy fractions, FOLFOX, or capecitabine doses were found. Conclusions and Relevance Pembrolizumab added to chemoradiotherapy as part of total neoadjuvant therapy was suggested to be safe; however, the NAR score difference does not support further study. Trial Registration ClinicalTrials.gov Identifier: NCT02921256.
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Affiliation(s)
- Osama E Rahma
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medical Oncology, Dana-Farber Cancer Institute/Alliance, Boston, Massachusetts
| | - Greg Yothers
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Theodore S Hong
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, Massachusetts General Hospital, Boston
| | - Marcia M Russell
- NRG Oncology, Philadelphia, Pennsylvania.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Y Nancy You
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - William Parker
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medical Physics, McGill University Health Centre, Montréal, Quebec, Canada
| | | | - Linda H Colangelo
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter C Lucas
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Pathology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William A Hall
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee
| | - Lisa A Kachnic
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, New York.,SWOG Cancer Research Network, San Antonio, Texas
| | - Namrata Vijayvergia
- NRG Oncology, Philadelphia, Pennsylvania.,Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Mark A O'Rourke
- NRG Oncology, Philadelphia, Pennsylvania.,National Cancer Institute Community Oncology Research Program, Prisma Health Cancer Institute, Greenville, South Carolina
| | - Bryan A Faller
- Missouri Baptist Medical Center, Heartland Cancer Research, National Cancer Institute Community Oncology Research Program, St Louis
| | | | - Tracey E Schefter
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, University of Colorado Cancer Center, Aurora
| | - Katherine M Moxley
- NRG Oncology, Philadelphia, Pennsylvania.,Section of Gynecologic Oncology, University of Oklahoma Stephenson Cancer Center, Oklahoma City
| | - Radhika Kainthla
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Philip J Stella
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medical Oncology, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Elin Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Norman Wolmark
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Thomas J George
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medicine, University of Florida Health Cancer Center, Gainesville
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39
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Affiliation(s)
- David P Horowitz
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York.,Columbia University Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Karyn Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York.,Columbia University Herbert Irving Comprehensive Cancer Center, New York, New York
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40
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Abstract
Locally advanced, unresectable pancreatic ductal adenocarcinoma has a poor prognosis with a median overall survival of 10-16 months. It is defined by tumor involvement of neighboring blood vessels that precludes resection. Standard doses of conventionally fractionated radiation have had little effect on overall survival in this setting, although they are associated with improved progression-free survival and time off chemotherapy. Evolving radiotherapy techniques have allowed for higher, ablative doses of radiotherapy to target tumor while also respecting normal tissue constraints of neighboring radiosensitive structures in the gastrointestinal tract. Moreover, advancements in image guidance, organ motion management, and the use of adaptive planning have enabled safe delivery of higher, ablative doses of radiation. This has resulted in improved survival. This review will summarize the expanding role of radiotherapy in the management of locally advanced, unresectable pancreatic cancer.
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41
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Rahma OE, Yothers G, Hong TS, Russell MM, You YN, Parker W, Jacobs SA, Colangelo LH, Lucas PC, Gollub MJ, Hall WA, Kachnic LA, Vijayvergia N, Wolmark N, George TJ. NRG-GI002: A phase II clinical trial platform using total neoadjuvant therapy (TNT) in locally advanced rectal cancer (LARC)—Pembrolizumab experimental arm (EA) primary results. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.3_suppl.8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
8 Background: This NCTN multi-arm randomized phase II modular clinical trial platform utilizes TNT with parallel EAs in LARC. EAs are not intended for direct comparison, but rather to test a variety of sensitizers or hypotheses in a consistent and homogenous high-risk pt population with correlative biomarkers. Here we report the primary and available secondary endpoints (EPs). Methods: Stage II/III LARC pts (with ONE or more of the following: distal location [cT3-4 ≤5cm from anal verge, any N]; bulky [any cT4 or tumor within 3mm of mesorectal fascia]; high risk for metastatic disease [cN2]; or not a sphincter-sparing surgery [SSS] candidate) were randomized to neoadjuvant FOLFOX x 4mo → chemoRT (capecitabine with 50.4Gy +/- pembrolizumab 200mg IV Q3 wks x 6 doses) → surgery 8-12 wks following last dose of radiotherapy. Primary EP: Improvement in Neoadjuvant Rectal Cancer (NAR) score for EA v control potentially representing a 3-4% absolute OS improvement. Secondary EPs: Comparisons of OS, DFS, toxicity, pCR, cCR, therapy completion, negative surgical margins, sphincter sparing surgery (SSS), and exploratory assessments of molecular and radiographic predictors of response and distant failure. Binary EPs compared by Fisher’s exact test. Reported p-values are two-sided. Results: From 8/2018-5/2019, 185 pts were randomized to control (n=95) or pembrolizumab (n= 90). Baseline characteristics were relatively well balanced. 137 pts were evaluable for NAR (68 control, 69 pembrolizumab). Mean NAR was 14.08 for control (95% CI: 10.7-17.4) v 11.53 for pembrolizumab (CI: 8.5-14.6) (p=0.26). pCR=29.4% v 31.9% (p=0.75); cCR=13.6% v 13.9% (p=0.95); and SSS=71.0% v 59.4% (p=0.15). The side effects on Arm 3 were consistent with both CRT and pembrolizumab safety profile. Grade 3/4 AEs were slightly increased on the pembrolizumab arm during and after CRT (48.2 v 37.3%). There were 2 deaths during FOLFOX, one on the control arm due to sepsis; the other on the EA due to pneumonia. There were no statistically significant differences in RT (fractions, dose, boost fractions, or boost dose), FOLFOX or capecitabine doses. Conclusions: Pembrolizumab added to chemoRT as part of TNT was safe and without unexpected short-term toxicities but failed to improve the NAR score. The secondary endpoints including PFS and OS have not been reached. Correlative analysis for both T-cell and myeloid cell populations in the tissue and blood in addition to comprehensive cytokine analysis is ongoing. NCT02921256. Support: U10CA180868, -180822; UG1-189867; U24-196067. Clinical trial information: NCT02921256.
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Affiliation(s)
- Osama E. Rahma
- NRG Oncology, and Dana-Farber Cancer Institute/Alliance, Boston, MA
| | - Greg Yothers
- NRG Oncology, and The University of Pittsburgh, Pittsburgh, PA
| | | | - Marcia McGory Russell
- NRG Oncology, and The VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Y. Nancy You
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - William Parker
- NRG Oncology, and McGill University Health Centre, Montreal, QC, Canada
| | - Samuel A. Jacobs
- NRG Oncology, and The University of Pittsburgh Cancer Institute, Pittsburgh, PA
| | | | - Peter C. Lucas
- NRG Oncology, and University of Pittsburgh, Pittsburgh, PA
| | - Marc J Gollub
- NRG Oncology and Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Lisa A. Kachnic
- Columbia University Irving Medical Center/SWOG, New York, NY
| | | | - Norman Wolmark
- NRG Oncology, and The University of Pittsburgh, Pittsburgh, PA
| | - Thomas J. George
- NRG Oncology, and The University of Florida Health Cancer Center, Gainesville, FL
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Stewart MK, Kavalukas SL, Bonfield CM, Ciombor KK, Shi C, Kachnic LA, Hawkins AT. Rectothecal Fistula Secondary to a Tailgut Cyst With Malignant Transformation: An Abnormal Connection and Unusual Pathology. Am Surg 2020; 87:1126-1128. [PMID: 33338389 DOI: 10.1177/0003134820940733] [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: 11/16/2022]
Affiliation(s)
- Melissa K Stewart
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandra L Kavalukas
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Kristen K Ciombor
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chanjuan Shi
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lisa A Kachnic
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander T Hawkins
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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43
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Safran H, Winter KA, Wigle DA, DiPetrillo TA, Haddock MG, Hong TS, Leichman LP, Rajdev L, Resnick MB, Kachnic LA, Seaward SA, Mamon HJ, Diaz Pardo DA, Anderson CM, Shen X, Sharma AK, Katz AW, Salo JC, Leonard KL, Crane CH. Trastuzumab with trimodality treatment for esophageal adenocarcinoma with HER2 overexpression: NRG Oncology/RTOG 1010. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.4500] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
4500 Background: Trastuzumab is a monoclonal antibody against human epidermal growth factor receptor 2 (HER2). The primary objective of RTOG 1010 was to determine if trastuzumab increases disease-free survival (DFS) when combined with trimodality treatment for patients with HER2 overexpressing esophageal adenocarcinoma. Methods: This open label, randomized phase III trial included patients with newly diagnosed stage T1N1-2, T2-3N0-2 adenocarcinoma of the esophagus involving the mid, distal, or esophagogastric junction and up to 5cm of the stomach. All patients received chemotherapy (C) of paclitaxel, 50mg/m2 and carboplatin AUC = 2, weekly for 6 weeks, with radiation (XRT: 3D-CRT or IMRT, 50.4 Gy in 28 fractions) followed by surgery. Patients were randomized 1:1 to receive weekly trastuzumab 4mg/kg week 1 then 2mg/kg/weekly x 5 during CXRT then 6 mg/kg for 1 dose prior to surgery and 6mg/kg every 3 weeks for 13 treatments after surgery. HER2 status was determined by IHC and gene amplification by FISH. With a 2-sided alpha of 0.05, 162 DFS events provide 90% power to detect a signal for an increase in median DFS from 15 to 25 months. DFS and overall survival (OS) were estimated by the Kaplan-Meier method. and arms were compared using the log rank test. The Cox proportional hazards model was used to analyze treatment effect. Results: 571 patients were entered for assessment of HER2 expression, 203 HER2+ patients randomized. The median follow-up for alive patients is 5.0 years. The estimated 2, 3, and 4-year DFS (95% CI) for the CXRT +trastuzumab arm were 41.8% (31.8%, 51.7%), 34.3% (24.7%, 43.9%), and 33.1% (23.6%, 42.7%), respectively, and for the CXRT arm were 40.0% (30.0%, 49.9%), 33.4% (23.8%, 43.0%), and 30.1% (20.7%, 39.4%), respectively; log-rank p = 0.85. The median DFS time is 19.6 months (13.5-26.2) for the CXRT +trastuzumab arm compared to 14.2 months (10.5-23.0) for the CXRT arm. The hazard ratio (95% CI) comparing the DFS of CXRT+trastuzumab arm to the CXRT arm was 0.97 (0.69, 1.36). The median OS time was 38.5 months (26.2-70.4) for the CXRT+trastuzumab arm compared to 38.9 months (29.0-64.5) for the CXRT arm, hazard ratio (95% CI): 1.01 (0.69, 1.47). There was no statistically significant increase in treatment-related toxicities with the addition of trastuzumab including no increase in cardiac events. Conclusions: The addition of trastuzumab to trimodality treatment did not improve DFS for patients with HER2 overexpressing esophageal adenocarcinoma. Supported by NCI grants U10CA180868, UG1CA189867, U10CA180822 and Genentech. Clinical trial information: NCT01196390 .
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Affiliation(s)
- Howard Safran
- Brown University Oncology Research Group, Providence, RI
| | - Kathryn A. Winter
- Statistical Center, Radiation Therapy Oncology Group, Philadelphia, PA
| | | | | | | | - Theodore S. Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | | | - Lakshmi Rajdev
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | | | | | | | | | | | | | - Xinglei Shen
- University of Kansas Cancer Center, Westwood, KS
| | | | - Alan W. Katz
- University of Rochester, James P. Wilmot Cancer Institute, Rochester, NY
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Brown PD, Gondi V, Pugh S, Tome WA, Wefel JS, Armstrong TS, Bovi JA, Robinson C, Konski A, Khuntia D, Grosshans D, Benzinger TLS, Bruner D, Gilbert MR, Roberge D, Kundapur V, Devisetty K, Shah S, Usuki K, Anderson BM, Stea B, Yoon H, Li J, Laack NN, Kruser TJ, Chmura SJ, Shi W, Deshmukh S, Mehta MP, Kachnic LA. Hippocampal Avoidance During Whole-Brain Radiotherapy Plus Memantine for Patients With Brain Metastases: Phase III Trial NRG Oncology CC001. J Clin Oncol 2020; 38:1019-1029. [PMID: 32058845 PMCID: PMC7106984 DOI: 10.1200/jco.19.02767] [Citation(s) in RCA: 413] [Impact Index Per Article: 103.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Radiation dose to the neuroregenerative zone of the hippocampus has been found to be associated with cognitive toxicity. Hippocampal avoidance (HA) using intensity-modulated radiotherapy during whole-brain radiotherapy (WBRT) is hypothesized to preserve cognition. METHODS This phase III trial enrolled adult patients with brain metastases to HA-WBRT plus memantine or WBRT plus memantine. The primary end point was time to cognitive function failure, defined as decline using the reliable change index on at least one of the cognitive tests. Secondary end points included overall survival (OS), intracranial progression-free survival (PFS), toxicity, and patient-reported symptom burden. RESULTS Between July 2015 and March 2018, 518 patients were randomly assigned. Median follow-up for alive patients was 7.9 months. Risk of cognitive failure was significantly lower after HA-WBRT plus memantine versus WBRT plus memantine (adjusted hazard ratio, 0.74; 95% CI, 0.58 to 0.95; P = .02). This difference was attributable to less deterioration in executive function at 4 months (23.3% v 40.4%; P = .01) and learning and memory at 6 months (11.5% v 24.7% [P = .049] and 16.4% v 33.3% [P = .02], respectively). Treatment arms did not differ significantly in OS, intracranial PFS, or toxicity. At 6 months, using all data, patients who received HA-WBRT plus memantine reported less fatigue (P = .04), less difficulty with remembering things (P = .01), and less difficulty with speaking (P = .049) and using imputed data, less interference of neurologic symptoms in daily activities (P = .008) and fewer cognitive symptoms (P = .01). CONCLUSION HA-WBRT plus memantine better preserves cognitive function and patient-reported symptoms, with no difference in intracranial PFS and OS, and should be considered a standard of care for patients with good performance status who plan to receive WBRT for brain metastases with no metastases in the HA region.
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Affiliation(s)
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Warrenville, IL
| | - Stephanie Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - Wolfgang A. Tome
- Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, NY
| | | | | | - Joseph A. Bovi
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI
| | | | | | - Deepak Khuntia
- East Bay Radiation Oncology Center, Eden Medical Center, Castro Valley, CA
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Deborah Bruner
- Winship Cancer Institute of Emory University, Atlanta, GA
| | - Mark R. Gilbert
- National Cancer Institute Center for Cancer Research, Bethesda, MD
| | - David Roberge
- CHUM-Hôtel-Dieu de Montréal, Montreal, Quebec, Canada
| | | | - Kiran Devisetty
- Wayne State University, Karmanos Cancer Institute, Detroit, MI
| | - Sunjay Shah
- ChristianaCare National Cancer Institute Community Oncology Research Program, Newark, DE
| | | | | | - Baldassarre Stea
- University of Arizona Medical Center-University Campus, Tucson, AZ
| | - Harold Yoon
- Heartland Cancer Research National Cancer Institute Community Oncology Research Program, Decatur, IL
| | - Jing Li
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Steven J. Chmura
- The University of Chicago Comprehensive Cancer Center, Chicago, IL
| | - Wenyin Shi
- Thomas Jefferson University Hospital, Philadelphia, PA
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | - Lisa A. Kachnic
- Vanderbilt University Medical Center, Ingram Cancer Center, Nashville, TN
| | - for NRG Oncology
- Mayo Clinic, Rochester, MN
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Warrenville, IL
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
- Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, NY
- The University of Texas MD Anderson Cancer Center, Houston, TX
- National Cancer Institute Center for Cancer Research, Bethesda, MD
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI
- Washington University in St Louis, St Louis, MO
- Chester County Hospital, West Chester, PA
- East Bay Radiation Oncology Center, Eden Medical Center, Castro Valley, CA
- Winship Cancer Institute of Emory University, Atlanta, GA
- CHUM-Hôtel-Dieu de Montréal, Montreal, Quebec, Canada
- Saskatoon Cancer Center, Saskatoon, Saskatchewan, Canada
- Wayne State University, Karmanos Cancer Institute, Detroit, MI
- ChristianaCare National Cancer Institute Community Oncology Research Program, Newark, DE
- University of Rochester, Rochester, NY
- University of Wisconsin Hospitals and Clinics, Madison, WI
- University of Arizona Medical Center-University Campus, Tucson, AZ
- Heartland Cancer Research National Cancer Institute Community Oncology Research Program, Decatur, IL
- Northwestern Memorial Hospital, Chicago, IL
- The University of Chicago Comprehensive Cancer Center, Chicago, IL
- Thomas Jefferson University Hospital, Philadelphia, PA
- Miami Cancer Institute, Miami, FL
- Vanderbilt University Medical Center, Ingram Cancer Center, Nashville, TN
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45
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Yeung AR, Pugh SL, Klopp AH, Gil KM, Wenzel L, Westin SN, Gaffney DK, Small W, Thompson S, Doncals DE, Cantuaria GHC, Yaremko BP, Chang A, Kundapur V, Mohan DS, Haas ML, Kim YB, Ferguson CL, Deshmukh S, Bruner DW, Kachnic LA. Improvement in Patient-Reported Outcomes With Intensity-Modulated Radiotherapy (RT) Compared With Standard RT: A Report From the NRG Oncology RTOG 1203 Study. J Clin Oncol 2020; 38:1685-1692. [PMID: 32073955 DOI: 10.1200/jco.19.02381] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [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
PURPOSE In oncology trials, the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) is the standard tool for reporting adverse events (AEs), but it may underreport symptoms experienced by patients. This analysis of the NRG Oncology RTOG 1203 compared symptom reporting by patients and clinicians during radiotherapy (RT). PATIENTS AND METHODS Patients with cervical or endometrial cancer requiring postoperative RT were randomly assigned to standard 4-field RT or intensity-modulated RT (IMRT). Patients completed the 6-item patient-reported outcomes version of the CTCAE (PRO-CTCAE) for GI toxicity assessing abdominal pain, diarrhea, and fecal incontinence at various time points. Patients reported symptoms on a 5-point scale. Clinicians recorded these AEs as CTCAE grades 1 to 5. Clinician- and patient-reported AEs were compared using McNemar's test for rates > 0%. RESULTS Of 278 eligible patients, 234 consented and completed the PRO-CTCAE. Patients reported high-grade abdominal pain 19.1% (P < .0001), high-grade diarrhea 38.5% (P < .0001), and fecal incontinence 6.8% more frequently than clinicians. Similar effects were seen between grade ≥ 1 CTCAE toxicity and any-grade patient-reported toxicity. Between-arm comparison of patient-reported high-grade AEs revealed that at 5 weeks of RT, patients who received IMRT experienced fewer GI AEs than patients who received 4-field pelvic RT with regard to frequency of diarrhea (18.2% difference; P = .01), frequency of fecal incontinence (8.2% difference; P = .01), and interference of fecal incontinence (8.5% difference; P = .04). CONCLUSION Patient-reported AEs showed a reduction in symptoms with IMRT compared with standard RT, whereas clinician-reported AEs revealed no difference. Clinicians also underreported symptomatic GI AEs compared with patients. This suggests that patient-reported symptomatic AEs are important to assess in this disease setting.
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Affiliation(s)
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | | | | | | | - David K Gaffney
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | - Spencer Thompson
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | | | | | | - Amy Chang
- Pamela Youde Nethersole Eastern Hospital, Hong Kong, Special Administrative Region, People's Republic of China
| | | | | | | | - Yong Bae Kim
- Severance Hospital, Yonsei University Health System, Seoul, South Korea
| | | | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
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Chandra RA, Kachnic LA, Thomas CR. Disease Sites. Hematol Oncol Clin North Am 2020; 34:xv-xvi. [DOI: 10.1016/j.hoc.2019.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chandra RA, Kachnic LA, Thomas CR. Current Issues and Techniques. Hematol Oncol Clin North Am 2019; 33:xiii-xiv. [PMID: 31668217 DOI: 10.1016/j.hoc.2019.09.001] [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: 11/24/2022]
Affiliation(s)
- Ravi A Chandra
- Department of Radiation Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, CHONY North, B Level, Room 11, New York, NY 10032, USA.
| | - Charles R Thomas
- Department of Radiation Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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48
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Wallner PE, Kachnic LA, Alektiar KM, Davis BJ, Hardenbergh PH, Ng AK. The American Board of Radiology Initial Certification in Radiation Oncology: Moving Forward Through Collaboration. Int J Radiat Oncol Biol Phys 2019; 104:21-23. [PMID: 30967226 DOI: 10.1016/j.ijrobp.2019.01.090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 01/21/2019] [Accepted: 01/25/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Paul E Wallner
- 21st Century Oncology, Inc, Ft. Myers, Florida; The American Board of Radiology, Tucson, Arizona.
| | | | | | | | | | - Andrea K Ng
- Brigham & Women's Hospital, Boston, Massachusetts
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Bovi JA, Pugh SL, Sabsevitz D, Robinson CG, Paulson E, Mehta MP, Gondi V, Kundapur V, Shahin MS, Chao ST, Machtay M, DeNittis AS, Laack NN, Greenspoon JN, Moore KN, Huang J, Dominello MM, Kachnic LA. Pretreatment Volume of MRI-Determined White Matter Injury Predicts Neurocognitive Decline After Hippocampal Avoidant Whole-Brain Radiation Therapy for Brain Metastases: Secondary Analysis of NRG Oncology Radiation Therapy Oncology Group 0933. Adv Radiat Oncol 2019; 4:579-586. [PMID: 31673651 PMCID: PMC6817553 DOI: 10.1016/j.adro.2019.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 04/22/2019] [Revised: 06/26/2019] [Accepted: 07/08/2019] [Indexed: 12/02/2022] Open
Abstract
Purpose NRG Oncology's RTOG 0933 demonstrated benefits to memory preservation after hippocampal avoidant whole-brain radiation therapy (HA-WBRT), the avoidance of radiation dose to the hippocampus (using intensity modulated radiation planning and delivery techniques) during WBRT, supporting the hypothesis of hippocampal radiosensitivity and associated memory specificity. However, some patients demonstrated cognitive decline, suggesting mechanisms outside hippocampal radiosensitivity play a role. White matter injury (WMI) has been implicated in radiation therapy–induced neurocognitive decline. This secondary analysis explored the relationship between pretreatment WMI and memory after HA-WBRT. Methods and Materials Volumetric analysis of metastatic disease burden and disease-unrelated WMI was conducted on the pretreatment magnetic resonance image. Correlational analyses were performed examining the relationship between pretreatment WMI and Hopkins Verbal Learning Test-Revised (HVLT-R) outcomes at baseline and 4 months after HA-WBRT. Results In the study, 113 patients received HA-WBRT. Of 113 patients, 33 underwent pretreatment and 4-month posttreatment HVLT testing and pretreatment postcontrast volumetric T1 and axial T2/fluid-attenuated inversion recovery magnetic resonance imaging. Correlation was found between larger volumes of pretreatment WMI and decline in HVLT-R recognition (r = 0.54, P < .05), and a correlational trend was observed between larger volume of pretreatment WMI and decline in HVLT-R delayed recall (r = 0.31, P = .08). Patients with higher pretreatment disease burden experienced a greater magnitude of stability or positive shift in HVLT-R recall and delayed recall after HA-WBRT (r = –0.36 and r = –0.36, P < .05), compared to the magnitude of stability or positive shift in those with lesser disease burden. Conclusions In patients receiving HA-WBRT for brain metastases, extent of pretreatment WMI predicts posttreatment memory decline, suggesting a mechanism for radiation therapy–induced neurocognitive toxicity independent of hippocampal stem cell radiosensitivity. Stability or improvement in HVLT after HA-WBRT for patients with higher pretreatment intracranial metastatic burden supports the importance of WBRT-induced intracranial control on neurocognition.
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Affiliation(s)
- Joseph A Bovi
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - David Sabsevitz
- Department of Psychiatry and Psychology, Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Eric Paulson
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Minesh P Mehta
- Department of Radiation Oncology, Baptist Hospital of Miami, Miami, Florida
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center Warrenville and Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Vijayananda Kundapur
- Department of Radiation Oncology, Cross Cancer Institute, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mark S Shahin
- Thomas Jefferson University Hospital, Abington Memorial Hospital, Gynecologic Oncology, Abington, Pennsylvania
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mitch Machtay
- Department of Radiation Oncology, University Hospitals of Cleveland, Case Western Reserve, Cleveland, Ohio
| | - Albert S DeNittis
- Department of Radiation Oncology, Main Line CCOP Lankenau Medical Center, Philadelphia, Pennsylvania
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey N Greenspoon
- Division of Radiation Oncology, Department of Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton Ontario, Canada
| | - Kathleen N Moore
- University of Oklahoma Health Sciences Center, Section of Gynecologic Oncology, Oklahoma City, Oklahoma
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Michael M Dominello
- Division of Radiation Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
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50
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George TJ, Yothers G, Hong TS, Russell MM, You YN, Parker W, Jacobs SA, Lucas PC, Gollub MJ, Hall WA, Kachnic LA, Vijayvergia N, Wolmark N. NRG-GI002: A phase II clinical trial platform using total neoadjuvant therapy (TNT) in locally advanced rectal cancer (LARC)—First experimental arm (EA) initial results. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.3505] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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
3505 Background: This NCTN multi-arm randomized phase II modular clinical trial platform utilizes TNT with parallel EAs in LARC. EAs are not intended for direct comparison, but rather to test a variety of hypotheses in a consistent high-risk pt population with correlative biomarkers. Primary endpoint (EP) and available secondary EPs from the first EA using veliparib (a PARPi) are reported. NCT02921256. Methods: Stage II/III pts with LARC (with any ONE of the following: distal location [cT3-4 ≤5cm from anal verge, any N]; bulky [any cT4 or tumor within 3mm of mesorectal fascia]; high risk for metastatic disease [cN2]; or not a sphincter-sparing surgery [SSS] candidate) were randomized to neoadjuvant FOLFOX (x 4mo) → chemoRT (cape with 50.4Gy +/- veliparib 400mg PO BID) → surgery 8-12 wks later. Primary EP: 4 point reduction in Neoadjuvant Rectal Cancer (NAR) score with a one-sided α = 0.10 and 80% power. NAR compared by linear model controlling for stratification and possibly other factors. Secondary EPs: OS, DFS, toxicity, pCR, cCR, therapy completion, negative surgical margins, and SSS. Binary EPs compared by Fisher’s exact test. Reported p-values are two-sided. Results: From 10/2016 - 2/2018, 178 pts were randomized (88 control, 90 veliparib). Baseline characteristics were balanced except for candidate for SSS at entry (39% control, 61% veliparib). 140 pts were evaluable for NAR (72 control, 68 veliparib). Mean NAR was 12.6 control (95% CI: 9.8–15.3) vs 13.7 for veliparib (CI: 10.2–17.2). Controlling for stratification (p = 0.69) or stratification and candidate for SSS (p = 0.78), NAR difference was not significant. pCR = 21.6% vs 33.8% (p = 0.14); cCR = 28.2% vs 33.3% (p = 0.60); and SSS = 52.5% vs 59.3% (p = 0.43). Most common grade 3/4 AEs were diarrhea and cytopenias. The EA had two deaths (cardiac arrest [FOLFOX]; enterocolitis [chemoRT]). Conclusions: Veliparib added to chemoRT as part of TNT was safe and without unexpected short-term toxicities but failed to improve the NAR score. Support: U10CA180868, -180822; UG1-189867; U24-196067; AbbVie. Clinical trial information: NCT02921256.
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Affiliation(s)
- Thomas J. George
- NRG Oncology, and The University of Florida Health Cancer Center, Gainesville, FL
| | - Greg Yothers
- NRG Oncology, and The University of Pittsburgh, Pittsburgh, PA
| | | | - Marcia McGory Russell
- NRG Oncology, and The VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Y. Nancy You
- NRG Oncology, and The University of Texas MD Anderson Cancer Center, Houston, TX
| | - William Parker
- NRG Oncology, and McGill University Health Centre, Montreal, QC, Canada
| | - Samuel A. Jacobs
- NRG Oncology,and The University of Pittsburgh Cancer Institute, Pittsburgh, PA
| | - Peter C. Lucas
- NRG Oncology, and University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | | | - Lisa A. Kachnic
- Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, TN
| | | | - Norman Wolmark
- NRG Oncology, and The Allegheny Health Network Cancer Institute, Pittsburgh, PA
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