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Sayan M, Chen MH, Loffredo M, McMahon E, Moningi S, Orio PF, Nguyen PL, D'Amico AV. Elective Pelvic Lymph Node Radiation Therapy and the Risk of Death in Patients With Unfavorable-Risk Prostate Cancer: A Postrandomization Analysis. J Clin Oncol 2024:JCO2302394. [PMID: 38691823 DOI: 10.1200/jco.23.02394] [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: 11/03/2023] [Revised: 12/19/2023] [Accepted: 03/07/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE Although a contemporary randomized clinical trial has led to the use of whole-pelvic radiation therapy (WPRT), long-term data evaluating a potential reduction in mortality are lacking and are addressed in the current study. MATERIALS AND METHODS From 2005 to 2015, 350 men with localized, unfavorable-risk prostate cancer (PC) were randomly assigned to receive androgen deprivation therapy (ADT) and RT plus docetaxel versus ADT and RT. Treatment of the pelvic lymph nodes was at the discretion of the treating physician. Multivariable Cox and Fine and Grays regression analyses were performed to assess whether a significant association existed between radiation treatment volume and all-cause mortality (ACM) and PC-specific mortality (PCSM), respectively, adjusting for known PC prognostic factors and comorbidity. An interaction term between age (categorized by dichotomization at 65 years to enable clinical interpretation and applicability of the results and which approximates the median (66 years [IQR, 61-70]) and radiation treatment volume was included in the analysis. RESULTS After a median follow-up of 10.20 years (IQR, 7.96-11.41), 89 men died (25.43%); of these, 42 died of PC (47.19%). Of the 350 randomly assigned patients, 88 (25.14%) received WPRT. In men younger than 65 years, WPRT was associated with a significantly lower ACM risk (adjusted hazard ratio [AHR], 0.33 [95% CI, 0.11 to 0.97]; P = .04) and lower PCSM risk (AHR, 0.17 [95% CI, 0.02 to 1.35]; P = .09) after adjusting for covariates, whereas this was not the case for men 65 years or older. CONCLUSION WPRT has the potential to reduce mortality in younger men with unfavorable-risk PC.
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Affiliation(s)
- Mutlay Sayan
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Ming-Hui Chen
- Department of Statistics, University of Connecticut, Storrs, CT
| | - Marian Loffredo
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Elizabeth McMahon
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Shalini Moningi
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Peter F Orio
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
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2
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Sayan M, Tuac Y, Akgul M, Pratt GK, Rowan MD, Akbulut D, Kucukcolak S, Tjio E, Moningi S, Leeman JE, Orio PF, Nguyen PL, D’Amico AV, Aktan C. Prognostic Significance of the Cribriform Pattern in Prostate Cancer: Clinical Outcomes and Genomic Alterations. Cancers (Basel) 2024; 16:1248. [PMID: 38610926 PMCID: PMC11011150 DOI: 10.3390/cancers16071248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
PURPOSE Given the diverse clinical progression of prostate cancer (PC) and the evolving significance of histopathological factors in its management, this study aimed to explore the impact of cribriform pattern 4 (CP4) on clinical outcomes in PC patients and examine its molecular characteristics. METHODS This retrospective study analyzed data from The Cancer Genome Atlas (TCGA) database and included PC patients who underwent radical prostatectomy (RP) and had pathology slides available for the assessment of CP4. A multivariable competing risk regression analysis was used to assess the association between CP4 and progression-free survival (PFS) while adjusting for established PC prognostic factors. The frequency of genomic alterations was compared between patients with and without CP4 using the Fisher's exact test. RESULTS Among the 394 patients analyzed, 129 (32.74%) had CP4. After a median follow-up of 40.50 months (IQR: 23.90, 65.60), the presence of CP4 was significantly associated with lower PFS (AHR, 1.84; 95% CI, 1.08 to 3.114; p = 0.023) after adjusting for covariates. Seven hub genes-KRT13, KRT5, KRT15, COL17A1, KRT14, KRT16, and TP63-had significantly lower mRNA expression levels in patients with CP4 compared to those without. CONCLUSIONS PC patients with CP4 have distinct genomic alterations and are at a high risk of disease progression following RP. Therefore, these patients may benefit from additional post-RP treatments and should be the subject of a prospective randomized clinical trial.
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Affiliation(s)
- Mutlay Sayan
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Yetkin Tuac
- Department of Statistics, Ankara University, 06100 Ankara, Türkiye;
| | - Mahmut Akgul
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY 12208, USA
| | - Grace K. Pratt
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Mary D. Rowan
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Dilara Akbulut
- Center for Cancer Research, Laboratory of Pathology, National Institutes of Health, Bethesda, MD 20892, USA
| | - Samet Kucukcolak
- Department of Pathology and Laboratory Medicine, Rutgers University, New Brunswick, NJ 08901, USA
| | - Elza Tjio
- Histopathology Department, Harrogate District Hospital, Harrogate HG2 7SX, UK
| | - Shalini Moningi
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Jonathan E. Leeman
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Peter F. Orio
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Paul L. Nguyen
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Anthony V. D’Amico
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Cagdas Aktan
- Department of Medical Biology, Faculty of Medicine, Bandirma Onyedi Eylul University, 10250 Balikesir, Türkiye
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3
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Sayan M, Langoe A, Aynaci O, Eren AA, Eren MF, Kazaz IO, Ibrahim Z, Al-Akelie OT, Al-Mansouri L, Abu-Hijlih R, Moningi S, Abou Chawareb E, El Hajj A, Orio PF, Mula-Hussain L. Prostate cancer presentation and management in the Middle East. BMC Urol 2024; 24:35. [PMID: 38336732 PMCID: PMC10858578 DOI: 10.1186/s12894-024-01427-6] [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: 12/23/2023] [Accepted: 02/05/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Although prostate cancer is a prevalent malignancy worldwide, its clinical presentation and management in the Middle East are not well-documented. This study aims to provide insights into the initial clinical presentation and management of prostate cancer in this region. METHODS A retrospective review was conducted on seven institutional databases from six Middle Eastern countries, including Türkiye, Lebanon, Iraq, Syria, Bahrain, and Jordan, to identify patients diagnosed with prostate cancer in 2021. Descriptive analysis was performed on the collected data to provide an overview of the demographic, clinical, and treatment variables. RESULTS A total of 1,136 patients were identified with a median age of 70 (range, 50-84). Most patients (78%) received their prostate cancer diagnosis after presenting with symptoms, as opposed to routine PSA screening. At the time of diagnosis, 35% of men had clinical T3 or T4 disease, 54% with Stage IV disease and 50% with Gleason score ≥ 8. Regarding treatment, 20% of non-metastatic and 22% of metastatic patients received no treatment. CONCLUSION Most men in this study sought prostate cancer evaluation due to symptoms and were subsequently diagnosed with advanced-stage disease, providing a foundation for future research aimed at understanding the underlying factors behind the observed trends and enabling informed interventions.
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Affiliation(s)
- Mutlay Sayan
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | | | - Ozlem Aynaci
- Karadeniz Technical University, Trabzon, Türkiye, Turkey
| | - Ayfer Ay Eren
- Kartal Dr. Lütfi Kirdar Education and Research Hospital, Istanbul, Turkey
| | - Mehmet Fuat Eren
- Marmara University, Istanbul Pendik Education and Research Hospital, Istanbul, Türkiye, Turkey
| | | | | | | | | | | | - Shalini Moningi
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Albert El Hajj
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Peter F Orio
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Layth Mula-Hussain
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
- College of Medicine, Ninevah University, Mosul, Ninevah, Iraq
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4
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Weng J, Mesko S, Chronowski G, Lee P, Choi S, Das P, Koong AC, French K, Aloia T, Ehlers R, Elrod-Joplin D, Kerr A, Smith R, Martinez W, Bloom E, Shah SJ, Ning MS, Liao Z, Herman J, Moningi S, Moreno AC, Nguyen QN. Optimizing Outpatient Radiation Oncology Consult Workflow by Using Time-Driven Activity-Based Costing: Efficiency and Financial Impacts. JCO Oncol Pract 2024:OP2300037. [PMID: 38330252 DOI: 10.1200/op.23.00037] [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: 01/20/2023] [Revised: 08/31/2023] [Accepted: 01/03/2024] [Indexed: 02/10/2024] Open
Abstract
PURPOSE Clinical efficiency is a key component of value-based health care. Our objective here was to identify workflow inefficiencies by using time-driven activity-based costing (TDABC) and evaluate the implementation of a new clinical workflow in high-volume outpatient radiation oncology clinics. METHODS Our quality improvement study was conducted with the Departments of GI, Genitourinary (GU), and Thoracic Radiation Oncology at a large academic cancer center and four community network sites. TDABC was used to create process maps and optimize workflow for outpatient consults. Patient encounter metrics were captured with a real-time status function in the electronic medical record. Time metrics were compared using Mann-Whitney U tests. RESULTS Individual patient encounter data for 1,328 consults before the intervention and 1,234 afterward across all sections were included. The median overall cycle time was reduced by 21% in GI (19 minutes), 18% in GU (16 minutes), and 12% at the community sites (9 minutes). The median financial savings per consult were $52 in US dollars (USD) for the GI, $33 USD for GU, $30 USD for thoracic, and $42 USD for the community sites. Patient satisfaction surveys (from 127 of 228 patients) showed that 99% of patients reported that their providers spent adequate time with them and 91% reported being seen by a care provider in a timely manner. CONCLUSION TDABC can effectively identify opportunities to improve clinical efficiency. Implementing workflow changes on the basis of our findings led to substantial reductions in overall encounter cycle times across several departments, as well as high patient satisfaction and significant financial savings.
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Affiliation(s)
- Julius Weng
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Shane Mesko
- Division of Radiation Oncology, Scripps MD Anderson Cancer Center, San Diego, CA
| | | | - Percy Lee
- Department of Radiation Oncology, City of Hope National Medical Center, Los Angeles, CA
| | - Seungtaek Choi
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Albert C Koong
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Katy French
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Thomas Aloia
- Surgical Oncology, Ascension Health, Pearland, TX
| | - Richie Ehlers
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, TX
| | | | - Ashley Kerr
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Regina Smith
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Wendi Martinez
- Institute for Cancer Care Innovation, MD Anderson Cancer Center, Houston, TX
| | - Elizabeth Bloom
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Shalin J Shah
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Matthew S Ning
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Zhongxing Liao
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Joseph Herman
- Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY
| | - Shalini Moningi
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Amy C Moreno
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Quynh-Nhu Nguyen
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
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Guevara M, Chen S, Thomas S, Chaunzwa TL, Franco I, Kann BH, Moningi S, Qian JM, Goldstein M, Harper S, Aerts HJWL, Catalano PJ, Savova GK, Mak RH, Bitterman DS. Large language models to identify social determinants of health in electronic health records. NPJ Digit Med 2024; 7:6. [PMID: 38200151 PMCID: PMC10781957 DOI: 10.1038/s41746-023-00970-0] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/15/2023] [Indexed: 01/12/2024] Open
Abstract
Social determinants of health (SDoH) play a critical role in patient outcomes, yet their documentation is often missing or incomplete in the structured data of electronic health records (EHRs). Large language models (LLMs) could enable high-throughput extraction of SDoH from the EHR to support research and clinical care. However, class imbalance and data limitations present challenges for this sparsely documented yet critical information. Here, we investigated the optimal methods for using LLMs to extract six SDoH categories from narrative text in the EHR: employment, housing, transportation, parental status, relationship, and social support. The best-performing models were fine-tuned Flan-T5 XL for any SDoH mentions (macro-F1 0.71), and Flan-T5 XXL for adverse SDoH mentions (macro-F1 0.70). Adding LLM-generated synthetic data to training varied across models and architecture, but improved the performance of smaller Flan-T5 models (delta F1 + 0.12 to +0.23). Our best-fine-tuned models outperformed zero- and few-shot performance of ChatGPT-family models in the zero- and few-shot setting, except GPT4 with 10-shot prompting for adverse SDoH. Fine-tuned models were less likely than ChatGPT to change their prediction when race/ethnicity and gender descriptors were added to the text, suggesting less algorithmic bias (p < 0.05). Our models identified 93.8% of patients with adverse SDoH, while ICD-10 codes captured 2.0%. These results demonstrate the potential of LLMs in improving real-world evidence on SDoH and assisting in identifying patients who could benefit from resource support.
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Affiliation(s)
- Marco Guevara
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Shan Chen
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Spencer Thomas
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
- Computational Health Informatics Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tafadzwa L Chaunzwa
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Idalid Franco
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Benjamin H Kann
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Shalini Moningi
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jack M Qian
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Susan Harper
- Adult Resource Office, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Hugo J W L Aerts
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
- Radiology and Nuclear Medicine, GROW & CARIM, Maastricht University, Maastricht, The Netherlands
| | - Paul J Catalano
- Department of Data Science, Dana-Farber Cancer Institute and Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Guergana K Savova
- Computational Health Informatics Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Raymond H Mak
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Danielle S Bitterman
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA, USA.
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA.
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Tsui JMG, Kehayias CE, Leeman JE, Nguyen PL, Peng L, Yang DD, Moningi S, Martin N, Orio PF, D'Amico AV, Bredfeldt JS, Lee LK, Guthier CV, King MT. Assessing the Feasibility of Using Artificial Intelligence-Segmented Dominant Intraprostatic Lesion for Focal Intraprostatic Boost With External Beam Radiation Therapy. Int J Radiat Oncol Biol Phys 2024; 118:74-84. [PMID: 37517600 DOI: 10.1016/j.ijrobp.2023.07.029] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/11/2023] [Accepted: 07/18/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE The delineation of dominant intraprostatic gross tumor volumes (GTVs) on multiparametric magnetic resonance imaging (mpMRI) can be subject to interobserver variability. We evaluated whether deep learning artificial intelligence (AI)-segmented GTVs can provide a similar degree of intraprostatic boosting with external beam radiation therapy (EBRT) as radiation oncologist (RO)-delineated GTVs. METHODS AND MATERIALS We identified 124 patients who underwent mpMRI followed by EBRT between 2010 and 2013. A reference GTV was delineated by an RO and approved by a board-certified radiologist. We trained an AI algorithm for GTV delineation on 89 patients, and tested the algorithm on 35 patients, each with at least 1 PI-RADS (Prostate Imaging Reporting and Data System) 4 or 5 lesion (46 total lesions). We then asked 5 additional ROs to independently delineate GTVs on the test set. We compared lesion detectability and geometric accuracy of the GTVs from AI and 5 ROs against the reference GTV. Then, we generated EBRT plans (77 Gy prostate) that boosted each observer-specific GTV to 95 Gy. We compared reference GTV dose (D98%) across observers using a mixed-effects model. RESULTS On a lesion level, AI GTV exhibited a sensitivity of 82.6% and positive predictive value of 86.4%. Respective ranges among the 5 RO GTVs were 84.8% to 95.7% and 95.1% to 100.0%. Among 30 GTVs mutually identified by all observers, no significant differences in Dice coefficient were detected between AI and any of the 5 ROs. Across all patients, only 2 of 5 ROs had a reference GTV D98% that significantly differed from that of AI by 2.56 Gy (P = .02) and 3.20 Gy (P = .003). The presence of false-negative (-5.97 Gy; P < .001) but not false-positive (P = .24) lesions was associated with reference GTV D98%. CONCLUSIONS AI-segmented GTVs demonstrate potential for intraprostatic boosting, although the degree of boosting may be adversely affected by false-negative lesions. Prospective review of AI-segmented GTVs remains essential.
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Affiliation(s)
- James M G Tsui
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Christopher E Kehayias
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jonathan E Leeman
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Luke Peng
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - David D Yang
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Shalini Moningi
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Neil Martin
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Peter F Orio
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jeremy S Bredfeldt
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Leslie K Lee
- Department of Radiology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christian V Guthier
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Martin T King
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts.
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7
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Moningi S, Choudhury AD, Martin NE, Nguyen PL, D'Amico AV, Cagney DN, Leeman JE. MR-guided prostate SBRT in prostate cancer patients with low-volume metastatic disease. World J Urol 2023; 41:3889-3894. [PMID: 37924333 DOI: 10.1007/s00345-023-04675-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/26/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Recent data have found an overall survival benefit from prostate-directed radiotherapy in patients with low-volume metastatic prostate cancer. Prostate SBRT is an attractive treatment in this setting and may be optimised with MR-guided adaptive treatment. Here, we share our institutional experience delivering stereotactic MR-guided adaptive prostate SBRT (SMART) for patients with low-volume metastatic disease. METHODS We reviewed patients with low-volume metastatic disease who received prostate SMART from October 2019 to December 2021 on a 0.35T MR-Linac. The cohort included 14 patients. Genitourinary (GU) and gastrointestinal (GI) toxicities were assessed using CTCAE v 5.0. Progression was defined as a change in systemic or hormonal therapy regimen as a result of PSA rise or disease progression. RESULTS The median follow-up time was 29 months. Seven patients had hormone sensitive prostate cancer and 7 had castrate resistant prostate cancer (CRPC). 13 patients received 36.25 Gy in 5 fractions and one patient received 33 Gy in 5 fractions. At the time of last follow-up, 11 patients had not experienced progression and three patients, all with CRPC, had experienced progression. No patients developed local progression in the prostate after SMART. One patient experienced acute grade 2 urinary toxicity (7%) and no patients experienced acute grade 2 GI toxicity (0%). No grade 3 + acute toxicities were observed. CONCLUSIONS Prostate SMART was found to be well tolerated and all patients had local control of disease within the prostate at the time of last follow-up. Prostate SMART may represent a low-risk and well-tolerated approach for delivering prostate-directed radiotherapy for patients with limited metastatic disease.
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Affiliation(s)
- Shalini Moningi
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Atish D Choudhury
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Neil E Martin
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anthony V D'Amico
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel N Cagney
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Taniguchi CM, Frakes JM, Aguilera TA, Palta M, Czito B, Bhutani MS, Colbert LE, Abi Jaoude J, Bernard V, Pant S, Tzeng CWD, Kim DW, Malafa M, Costello J, Mathew G, Rebueno N, Koay EJ, Das P, Ludmir EB, Katz MHG, Wolff RA, Beddar S, Sawakuchi GO, Moningi S, Slack Tidwell RS, Yuan Y, Thall PF, Beardsley RA, Holmlund J, Herman JM, Hoffe SE. Stereotactic body radiotherapy with or without selective dismutase mimetic in pancreatic adenocarcinoma: an adaptive, randomised, double-blind, placebo-controlled, phase 1b/2 trial. Lancet Oncol 2023; 24:1387-1398. [PMID: 38039992 DOI: 10.1016/s1470-2045(23)00478-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 07/28/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) has the potential to ablate localised pancreatic ductal adenocarcinoma. Selective dismutase mimetics sensitise tumours while reducing normal tissue toxicity. This trial was designed to establish the efficacy and toxicity afforded by the selective dismutase mimetic avasopasem manganese when combined with ablative SBRT for localised pancreatic ductal adenocarcinoma. METHODS In this adaptive, randomised, double-blind, placebo-controlled, phase 1b/2 trial, patients aged 18 years or older with borderline resectable or locally advanced pancreatic cancer who had received at least 3 months of chemotherapy and had an Eastern Cooperative Oncology Group performance status of 0-2 were enrolled at six academic sites in the USA. Eligible patients were randomly assigned (1:1), with block randomisation (block sizes of 6-12) with a maximum of 24 patients per group, to receive daily avasopasem (90 mg) or placebo intravenously directly before (ie, within 180 min) SBRT (50, 55, or 60 Gy in five fractions, adaptively assigned in real time by Bayesian estimates of 90-day safety and efficacy). Patients and physicians were masked to treatment group allocation, but not to SBRT dose. The primary objective was to find the optimal dose of SBRT with avasopasem or placebo as determined by the late onset EffTox method. All analyses were done on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, NCT03340974, and is complete. FINDINGS Between Jan 25, 2018, and April 29, 2020, 47 patients were screened, of whom 42 were enrolled (median age was 71 years [IQR 63-75], 23 [55%] were male, 19 [45%] were female, 37 [88%] were White, three [7%] were Black, and one [2%] each were unknown or other races) and randomly assigned to avasopasem (n=24) or placebo (n=18); the placebo group was terminated early after failing to meet prespecified efficacy parameters. At data cutoff (June 28, 2021), the avasopasem group satisfied boundaries for both efficacy and toxicity. Late onset EffTox efficacy response was observed in 16 (89%) of 18 patients at 50 Gy and six (100%) of six patients at 55 Gy in the avasopasem group, and was observed in three (50%) of six patients at 50 Gy and nine (75%) of 12 patients at 55 Gy in the placebo group, and the Bayesian model recommended 50 Gy or 55 Gy in five fractions with avasopasem for further study. Serious adverse events of any cause were reported in three (17%) of 18 patients in the placebo group and six (25%) of 24 in the avasopasem group. In the placebo group, grade 3 adverse events within 90 days of SBRT were abdominal pain, acute cholangitis, pyrexia, increased blood lactic acid, and increased lipase (one [6%] each); no grade 4 events occurred. In the avasopasem group, grade 3-4 adverse events within 90 days of SBRT were acute kidney injury, increased blood alkaline phosphatase, haematoma, colitis, gastric obstruction, lung infection, abdominal abscess, post-surgical atrial fibrillation, and pneumonia leading to respiratory failure (one [4%] each).There were no treatment-related deaths but one late death in the avasopasem group due to sepsis in the setting of duodenal obstruction after off-study treatment was reported as potentially related to SBRT. INTERPRETATION SBRT that uses 50 or 55 Gy in five fractions can be considered for patients with localised pancreatic ductal adenocarcinoma. The addition of avasopasem might further enhance disease outcomes. A larger phase 2 trial (GRECO-2, NCT04698915) is underway to validate these results. FUNDING Galera Therapeutics.
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Affiliation(s)
- Cullen M Taniguchi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica M Frakes
- Department of Radiation Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Todd A Aguilera
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Manisha Palta
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, USA
| | - Brian Czito
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren E Colbert
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Abi Jaoude
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vincent Bernard
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shubham Pant
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dae Won Kim
- Department of Gastrointestinal Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - James Costello
- Department of Diagnostic Imaging and Interventional Radiology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Geena Mathew
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neal Rebueno
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sam Beddar
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel O Sawakuchi
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalini Moningi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca S Slack Tidwell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter F Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Joseph M Herman
- Department of Radiation Oncology, Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, Hempstead, NY, USA
| | - Sarah E Hoffe
- Department of Radiation Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
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Sayan M, Eren AA, Alali B, Mohammadipour S, Vahedi F, Daneshmand B, Abbas W, Hawsawi Y, Nader T, Joseph J, Wahby R, Ozgenc I, Mula-Hussain L, Moningi S, Orio PF, Eren MF. Prostate Cancer Awareness in the Middle East. Int J Radiat Oncol Biol Phys 2023; 117:e433-e434. [PMID: 37785413 DOI: 10.1016/j.ijrobp.2023.06.1602] [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) A better understanding of cancer awareness is crucial to allow the appropriate implementation of interventions to improve screening and diagnosis. While the incidence of prostate cancer has been reported to increase over the last decade in the Middle East, data on prostate cancer awareness in this region remains limited. Therefore, an assessment of prostate cancer awareness is critically needed. The current study addresses this urgent need by investigating the level of awareness of prostate cancer among the general public in the Middle East. MATERIALS/METHODS A cross-sectional survey of men residing in 13 Middle Eastern countries was conducted in 2022. A validated prostate cancer awareness questionnaire was used to assess participants' knowledge on several domains of prostate cancer. Men younger than 40 years of age or history of prostate cancer were excluded from the study. RESULTS A total of 4,431 men completed the survey. The median age was 49 (range, 40-81) and the majority of participants (81%) had a formal education. Most participants (90%) were married and only 30% had a family history of cancer. Most participants (84%) reported hearing about prostate cancer in the past but only 31% of the participants recognized that prostate cancer is the most common malignancy in men and 22% thought that prostate cancer affects both men and women. Awareness of risk factors for prostate cancer was low: 29% of the participants recognized family history as a risk factor and 30% associated increasing age with prostate cancer. Most participants were not aware of screening, specifically only 19% of the participants knew that PSA test is used for PC screening. In terms of prognosis, participants thought that the majority of prostate cancer patients (mean, 75%) die due to their disease as opposed to old age or another cause of death. CONCLUSION Although the Middle Eastern men are familiar with the existence of prostate cancer, they are uninformed about the disease outcomes, risk factors, and screening. Overall, these results indicate critically low levels of awareness of prostate cancer in the Middle East. Thus, there is a vital need to target this population for practical interventions to increase awareness, in addition to screening and earlier diagnosis.
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Affiliation(s)
- M Sayan
- Dana Farber Cancer Institute, Boston, MA
| | - A Ay Eren
- Kartal Dr. Lütfi Kırdar Education and Research Hospital, Istanbul, Turkey
| | - B Alali
- Jaber Al Ahmad Hospital, Kuwait, Kuwait
| | | | - F Vahedi
- University of Tehran, Tehran, Iran (Islamic Republic of Iran)
| | | | - W Abbas
- Tehran University of Medical Sciences, Tehran, Iran (Islamic Republic of Iran)
| | - Y Hawsawi
- Al-Faisal University, Jeddah, Saudi Arabia
| | - T Nader
- Faculty of Medicine of Damascus University, Damascus, Syrian Arab Republic
| | - J Joseph
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - R Wahby
- Galala University, Suez, Egypt
| | - I Ozgenc
- University of Nicosia Medical School, Egkomi, Cyprus
| | | | - S Moningi
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA
| | - P F Orio
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - M F Eren
- Marmara Universitesi Hastanesi, Istanbul, Turkey
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10
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Sayan M, Aynaci O, Eren AA, Eren MF, Kazaz IO, Ibrahim Z, Al-Akelie OT, Al-Mansouri L, Abuhijlih R, Moningi S, El Hajj A, Mula-Hussain L, Orio PF. Clinical Presentation and Management of Prostate Cancer in the Middle East. Int J Radiat Oncol Biol Phys 2023; 117:e433. [PMID: 37785412 DOI: 10.1016/j.ijrobp.2023.06.1601] [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) Prostate cancer is one of the most common malignancies worldwide and the incidence rate continues to increase in the Middle East. In the absence of large well-established cancer registries, there are no data to reflect the disease stage at initial presentation and patterns of care in this region. In order to mitigate the disease burden and help stakeholders to implement new policies to improve patient outcomes, it is important to study the disease stage at the initial presentation. The purpose of this study was to evaluate the clinical presentation and treatment of prostate cancer in the Middle East. MATERIALS/METHODS We performed a retrospective review of 7 institutional databases in 6 Middle Eastern countries to identify patients diagnosed with prostate cancer in 2021. Demographic, clinical, and treatment variables were abstracted. Patients who missed ≥2 scheduled radiation therapy (RT) appointments (excluding planned treatment breaks) were deemed "noncompliant." RESULTS A total of 1,132 patients were identified with a median age was 70 (range, 50-84). Most of the patients (78%) were diagnosed after developing symptoms and not on routine PSA screening. Diagnostic workup was completed in 87% of the patient. At time of diagnosis, 35% men presented with clinical T3 or T4 disease, 53% with metastatic disease and 42% with Gleason score ≥ 8. Mean PSA at time of presentation was 84 ng/ml. Among the nonmetastatic patients, 23% underwent a prostatectomy, 48% received definitive RT with or without androgen deprivation therapy (ADT), 9% received ADT alone and 20% received no treatment. No brachytherapy was used. Hypofractionated RT was used in 49% patients and only 8% were deemed "noncompliant". Among the metastatic patients, 74% received ADT with or without additional systemic therapy, 25% had palliative RT and 22% received no treatment. CONCLUSION In this large cohort of prostate cancer patients in the Middle East, most men presented with symptoms and were found to have advanced-stage disease. However, substantial proportion of patients did not receive any treatment. Further interventions to optimize prostate cancer diagnosis and treatment in in the Middle East are urgently needed.
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Affiliation(s)
- M Sayan
- Dana Farber Cancer Institute, Boston, MA
| | - O Aynaci
- Karadeniz Technical University, Trabzon, Trabzon, Turkey
| | - A Ay Eren
- Kartal Dr. Lütfi Kırdar Education and Research Hospital, Istanbul, Turkey
| | - M F Eren
- Marmara Universitesi Hastanesi, Istanbul, Turkey
| | - I O Kazaz
- Karadeniz Technical University, Trabzon, Turkey
| | - Z Ibrahim
- King Hamad University Hospital, Al Sayh, Bahrain
| | - O T Al-Akelie
- Alamal National Hospital for Cancer Management, Baghdad, Iraq
| | | | | | - S Moningi
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA
| | - A El Hajj
- American University of Beirut Medical Center, Beirut, Lebanon
| | | | - P F Orio
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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11
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Eren MF, Kilic SS, Eren AA, Kaplan SO, Teke F, Kutuk T, Bicakci BC, Hathout L, Moningi S, Orio P, Atalar B, Sayan M. Radiation therapy for prostate cancer in Syrian refugees: facing the need for change. Front Public Health 2023; 11:1172864. [PMID: 37325331 PMCID: PMC10264678 DOI: 10.3389/fpubh.2023.1172864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/11/2023] [Indexed: 06/17/2023] Open
Abstract
Purpose To report the utilization of radiation therapy in Syrian refugee patients with prostate cancer residing in Turkey. Methods and materials A multi-institutional retrospective review including 14 cancer centers in Turkey was conducted to include 137 Syrian refugee patients with prostate cancer treated with radiation therapy (RT). Toxicity data was scored using the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. Noncompliance was defined as a patient missing two or more scheduled RT appointments. Results Advanced disease, defined as stage III or IV, was reported in 64.2% of patients while androgen deprivation therapy (ADT) was only administrated to 20% of patients. Conventionally fractionated RT with a median number of 44 fractions was delivered to all patients with curative intent (n = 61) while palliative RT (n = 76) was delivered with a median number of 10 fractions. The acute grade 3-4 toxicity rate for the entire cohort was 16%. Noncompliance rate was 42%. Conclusion Most Syrian refugee prostate cancer patients presented with advanced disease however ADT was seldom used. Despite the low treatment compliance rate, conventional fractionation was used in all patients. Interventions are critically needed to improve screening and increase the use of standard-of-care treatment paradigms, including hypofractionated RT and ADT.
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Affiliation(s)
- Mehmet Fuat Eren
- Marmara University Istanbul Pendik Education and Research Hospital, Istanbul, Türkiye
| | - Sarah S. Kilic
- Taussig Cancer Institute, Cancer Center, Cleveland Clinic, Cleveland, OH, United States
| | - Ayfer Ay Eren
- Istanbul Kartal Dr.Lutfi Kirdar Education and Research Hospital, Istanbul, Türkiye
| | | | | | - Tugce Kutuk
- Malatya Education and Research Hospital, Malatya, Türkiye
| | | | - Lara Hathout
- Rutgers Cancer Institute of New Jersey, The State University of New Jersey, New Brunswick, NJ, United States
| | - Shalini Moningi
- Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Peter Orio
- Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Mutlay Sayan
- Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
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12
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Derton A, Guevara M, Chen S, Moningi S, Kozono DE, Liu D, Miller TA, Savova GK, Mak RH, Bitterman DS. Natural Language Processing Methods to Empirically Explore Social Contexts and Needs in Cancer Patient Notes. JCO Clin Cancer Inform 2023; 7:e2200196. [PMID: 37235847 DOI: 10.1200/cci.22.00196] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/22/2023] [Accepted: 03/23/2023] [Indexed: 05/28/2023] Open
Abstract
PURPOSE There is an unmet need to empirically explore and understand drivers of cancer disparities, particularly social determinants of health. We explored natural language processing methods to automatically and empirically extract clinical documentation of social contexts and needs that may underlie disparities. METHODS This was a retrospective analysis of 230,325 clinical notes from 5,285 patients treated with radiotherapy from 2007 to 2019. We compared linguistic features among White versus non-White, low-income insurance versus other insurance, and male versus female patients' notes. Log odds ratios with an informative Dirichlet prior were calculated to compare words over-represented in each group. A variational autoencoder topic model was applied, and topic probability was compared between groups. The presence of machine-learnable bias was explored by developing statistical and neural demographic group classifiers. RESULTS Terms associated with varied social contexts and needs were identified for all demographic group comparisons. For example, notes of non-White and low-income insurance patients were over-represented with terms associated with housing and transportation, whereas notes of White and other insurance patients were over-represented with terms related to physical activity. Topic models identified a social history topic, and topic probability varied significantly between the demographic group comparisons. Classification models performed poorly at classifying notes of non-White and low-income insurance patients (F1 of 0.30 and 0.23, respectively). CONCLUSION Exploration of linguistic differences in clinical notes between patients of different race/ethnicity, insurance status, and sex identified social contexts and needs in patients with cancer and revealed high-level differences in notes. Future work is needed to validate whether these findings may play a role in cancer disparities.
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Affiliation(s)
- Abigail Derton
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA
| | - Marco Guevara
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Shan Chen
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Shalini Moningi
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - David E Kozono
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Dianbo Liu
- Mila-Quebec AI Institute, Montreal, QC, Canada
| | - Timothy A Miller
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Guergana K Savova
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Raymond H Mak
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Danielle S Bitterman
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, MA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Weng J, Mesko S, Das P, Chronowski G, Lee P, Choi S, Koong AC, French KE, Aloia TA, Ehlers RA, Elrod-Joplin D, Kerr A, Smith R, Martinez W, Shah SJ, Ning MS, Herman JM, Moningi S, Moreno AC, Nguyen Q. Optimizing outpatient oncology consult workflow using time-driven activity-based costing: Efficiency and financial impacts. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.009] [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
9 Background: Clinical efficiency is a key component of value-based healthcare, patient satisfaction, staff burnout, and institutional operational capacity. The objective of this study was to identify clinic inefficiencies using time driven activity-based costing (TDABC) and evaluate the implementation of a new clinical workflow in high volume, outpatient radiation oncology clinics. Methods: We conducted an IRB-approved quality improvement study in the Gastrointestinal (GI), Genitourinary (GU), and Thoracic Radiation (TRO) Oncology departments at a large academic cancer center and four additional network sites (HALs). TDABC methodology was used to create process maps and optimize consult workflow. Patient encounter metrics were captured utilizing a real-time status function in the electronic medical record (Epic Systems). Anonymous patient satisfaction telephone surveys were administered to patients at the HALs. Hourly wages were determined based on 2021 U.S. Bureau of Labor Statistics. Pre- vs post-implementation metrics were compared using the Mann-Whitney U test. Results: Consult data for 1328 patients pre-intervention and 1234 post-intervention across all sections was included. Median overall cycle time was reduced by 21% in GI (19 min, p < 0.001), 18% in GU (16 min, p < 0.001), and 12% in HALs (9 min, p < 0.001). The median interval between rooming and being seen by the attending physician decreased by 13% in GI (7 min, p < 0.001), 16% in GU (9 min, p < 0.001), 21% in TRO (10 min, p < 0.001), and 9% in HALS (4 min, p < 0.005). For each consult, there was a median financial savings of $29 for GI, $24 for GU, $5 for TRO, and $14 for HALs per consult. From patient satisfaction surveys (95/177), 99% of patients reported their providers spent adequate time with them, 85% reported their appointment began on time, and 91% reported being seen by a care provider in a timely manner. Conclusions: TDABC is a successful method to identify opportunities to improve clinical efficiency. Implementing workflow changes based upon these findings led to substantial reduction in overall encounter cycle times and patient wait times across multiple departments. Furthermore, patient satisfaction was high and there were significant financial savings with the new workflow. These findings may also have implications for reducing staff burnout and expanding clinical capacity across the magnitude of clinical enterprise.[Table: see text]
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Affiliation(s)
| | - Shane Mesko
- Scripps MD Anderson Cancer Center, San Deigo, CA
| | | | | | - Percy Lee
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Seungtaek Choi
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Richard A. Ehlers
- Department of Breast Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Nassau Bay, TX
| | | | | | | | | | | | | | | | | | | | - Quynh Nguyen
- University of Texas MD Anderson Cancer Center, Houston, TX
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Moningi S, Lei X, Fang P, Taniguchi CM, Holliday EB, Koay EJ, Koong AC, Ludmir EB, Minsky BD, Das P, Giordano SH, Smith GL. Contemporary use and outcomes of radiation and chemotherapy for unresectable pancreatic cancer. Clin Transl Radiat Oncol 2022; 35:9-16. [PMID: 35510142 PMCID: PMC9058953 DOI: 10.1016/j.ctro.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 04/15/2022] [Accepted: 04/16/2022] [Indexed: 11/25/2022] Open
Abstract
This study examines 5,624 patients with unresectable pancreatic cancer. Across “real-world” US practice, overall use of radiation treatment (RT) has declined. Among those receiving RT, stereotactic body radiation treatment (SBRT) increased. Contemporary risks of gastrointestinal complications after SBRT have decreased.
Background We assessed radiation treatment (RT) use and complications for unresectable pancreatic cancer in the US, comparing conventionally fractionated (CFRT) and stereotactic body radiation treatment (SBRT) to inform real-world expected outcomes and practice. Material and Methods We analyzed 5,624 patients with non-metastatic, unresectable pancreatic cancer (2,522 older patients age > 65, diagnosed 2006–2013 in Medicare linked data; and 3,102 younger patients age < 65, diagnosed 2006–2016 in MarketScan data), comparing CFRT vs. SBRT vs. chemotherapy alone. Cochran-Armitage tested temporal trends. Fisher’s Exact Test and proportional hazards models compared gastrointestinal (GI) complications. Healthcare payments (Consumer Price Index adjusted to 2015) through 12 months were compared using generalized linear regression models with log link and gamma distribution. Results RT use declined from 55% to 45% of older patients (2006–2013) and 52% to 47% of younger patients (2006–2016) (Ptrend < 0.001 both). Among RT patients, SBRT use increased to 10% of older patients and 12% of younger patients in the most recent years (Ptrend = 0.04 and < 0.001 respectively). Addition of RT was associated with more frequent GI bleeds, strictures, and fistulas (Δ= +3% to 9% excess events, all P ≤ 0.05). Temporal patterns suggested decreasing complications over time (Ptrend = 0.05 and 0.05 for older and younger patients). Among younger patients, there was no difference in GI complications for SBRT vs. CFRT (P > 0.05, all comparisons). Among older patients, increased complications were seen for SBRT in 1–4 fractions vs. CFRT (P < 0.05), but not SBRT in 5 fractions (P = 0.72). Healthcare payments were greatest for SBRT when compared with CFRT or chemotherapy under US Medicare (P < 0.001) and employer-based insurance (P < 0.001). Conclusion Real-world treatment has shifted toward more selectivity for RT in unresectable pancreatic cancer. However, SBRT uptake and improving trends in complications profiles represent opportunities to optimize current use and benefit. Findings are applicable to inform future comparative and cost effectiveness models of RT for this disease.
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Moningi S, Johnson H, Peng L, Leeman J, Phillips J, Crouse K, Pflanz L, Fitzgerald B, Orio P. Could an Academic Review of Pathology Lead to Changes in Patient Care in Men With Prostate Cancer? Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.914] [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: 11/15/2022]
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Hoffe S, Frakes JM, Aguilera TA, Czito B, Palta M, Brookes M, Schweizer C, Colbert L, Moningi S, Bhutani MS, Pant S, Tzeng CW, Tidwell RS, Thall P, Yuan Y, Moser EC, Holmlund J, Herman J, Taniguchi CM. Randomized, Double-Blinded, Placebo-controlled Multicenter Adaptive Phase 1-2 Trial of GC 4419, a Dismutase Mimetic, in Combination with High Dose Stereotactic Body Radiation Therapy (SBRT) in Locally Advanced Pancreatic Cancer (PC). Int J Radiat Oncol Biol Phys 2020; 108:1399-1400. [PMID: 33427657 DOI: 10.1016/j.ijrobp.2020.09.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S Hoffe
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - J M Frakes
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - T A Aguilera
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - B Czito
- Duke University Medical Center, Durham, NC
| | - M Palta
- Duke University Medical Center, Department of Radiation Oncology, Durham, NC
| | | | | | - L Colbert
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S Moningi
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - S Pant
- (10)University of Oklahoma Health Science Center, Stephenson Cancer Center, Department of Hematology & Oncology, Oklahoma City, OK
| | - C W Tzeng
- (11)The Univ of Texas MD Anderson Cancer Center, Houston, TX
| | - R S Tidwell
- (12)MD Anderson Cancer Center, Department of Biostatistics, Houston, TX
| | - P Thall
- (13)Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Y Yuan
- MD Anderson Cancer Center, Houston, TX
| | | | - J Holmlund
- (14)Galera Therapeutics Inc., Malvern, PA
| | - J Herman
- (15)Northwell Health Cancer Institute, Lake Success, NY
| | - C M Taniguchi
- (16)UT MD Anderson Cancer Center, Houston, TX; (17)Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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17
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Moningi S, Abi Jaoude J, Kouzy R, Lin D, Nguyen ND, Garcia Garcia CJ, Phan JL, Avila S, Smani D, Cazacu IM, Singh BS, Smith GL, Holliday EB, Koay EJ, Das P, Bhutani MS, Herman JM, Minsky BD, Koong AC, Taniguchi CM. Impact of Fiducial Marker Placement Before Stereotactic Body Radiation Therapy on Clinical Outcomes in Patients With Pancreatic Cancer. Adv Radiat Oncol 2020; 6:100621. [PMID: 33912734 PMCID: PMC8071717 DOI: 10.1016/j.adro.2020.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 08/04/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Localized pancreatic cancer is commonly treated with stereotactic body radiation therapy (SBRT), which often requires the placement of fiducial markers. We compared the clinical outcomes of patients with and without fiducial markers. Methods and Materials We retrospectively collected data on patients with pancreatic cancer treated with neoadjuvant SBRT at a single institution. Patients were divided into 2 groups based on the placement of a fiducial marker. Local recurrence was the primary outcome. Time to event endpoints were analyzed using COX regression. Results We included 96 patients with unresectable pancreatic cancer: 46 patients (47.9%) did not have a fiducial marker, and 50 patients (52.1%) had a fiducial placed. Patients in the fiducial group were older and had more locally advanced pancreatic cancer compared with those who did not have a fiducial placed. Most patients in both groups (92.7%) received chemotherapy before SBRT treatment. SBRT was delivered to a median of 36 Gy over 5 fractions in the no-fiducial group, and 38 Gy over 5 fractions in the fiducial group. At a median follow-up of 20 months, local recurrence was similar irrespective of fiducial placement (adjusted hazard ratio [aHR] 0.6, 95% CI 0.3-1.3, P = .59). Furthermore, no difference in overall survival was noted between the 2 groups (aHR 0.8, 95% CI 0.3-1.9, P = .65). In patients who eventually underwent surgery post-SBRT, no difference in surgical margins (P = .40) or lymphovascular invasion (P = .76) was noted between the 2 groups. No patient developed acute pancreatitis after fiducial placement. Conclusions Our data suggest that the use of fiducial markers does not negatively affect clinical outcomes in patients with localized pancreatic cancer. Prospective confirmation of our results is still needed.
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Affiliation(s)
- Shalini Moningi
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Ramez Kouzy
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel Lin
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Jae L Phan
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Santiago Avila
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel Smani
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Irina M Cazacu
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ben S Singh
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Grace L Smith
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Emma B Holliday
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eugene J Koay
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Joseph M Herman
- Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York
| | - Bruce D Minsky
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert C Koong
- University of Texas MD Anderson Cancer Center, Houston, Texas
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18
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Ludmir EB, Fuller CD, Moningi S, Mainwaring W, Lin TA, Miller AB, Jethanandani A, Espinoza AF, Verma V, Smith BD, Smith GL, VanderWalde NA, Holliday EB, Guadagnolo BA, Stinchcombe TE, Jagsi R, Gomez DR, Minsky BD, Rödel C, Fokas E. Sex-Based Disparities Among Cancer Clinical Trial Participants. J Natl Cancer Inst 2020; 112:211-213. [PMID: 31350545 DOI: 10.1093/jnci/djz154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 11/13/2022] Open
Abstract
Landmark investigation two decades ago demonstrated sex-based disparities among participants in cancer cooperative group trials. Although federal efforts have aimed to improve representation of female patients in government-sponsored research, less is known about sex disparities in the broader landscape of modern oncologic randomized controlled trials. Using ClinicalTrials.gov, we identified randomized controlled trials related to colorectal or lung cancer (the two most common non-sex-specific disease sites). Among the 147 included trials, the proportion of female patients enrolled on trial was on average 6.8% (95% confidence interval = -8.8% to -4.9%) less than the proportion of female patients in the population by disease site (P < .001). Whereas no statistically significant underrepresentation of women was noted within the 26 cooperative group trials, sex disparities were markedly heightened for the 121 noncooperative-group-sponsored trials. Furthermore, underrepresentation of women did not improve with time. Future efforts should therefore focus on addressing these pervasive sex-based enrollment disparities beyond cooperative group trials alone.
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Affiliation(s)
- Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C David Fuller
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shalini Moningi
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Timothy A Lin
- The University of Texas MD Anderson Cancer Center, Houston, TX.,Baylor College of Medicine, Houston, TX
| | | | - Amit Jethanandani
- The University of Texas MD Anderson Cancer Center, Houston, TX.,The University of Tennessee Health Science Center, Memphis, TN
| | | | - Vivek Verma
- Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | | | - Grace L Smith
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Emma B Holliday
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Daniel R Gomez
- The University of Texas MD Anderson Cancer Center, Houston, TX.,Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bruce D Minsky
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claus Rödel
- University of Frankfurt, Frankfurt, Germany.,German Cancer Research Center, Heidelberg, Germany.,German Cancer Consortium, Frankfurt, Germany.,Frankfurt Cancer Institute, Frankfurt, Germany
| | - Emmanouil Fokas
- University of Frankfurt, Frankfurt, Germany.,German Cancer Research Center, Heidelberg, Germany.,German Cancer Consortium, Frankfurt, Germany.,Frankfurt Cancer Institute, Frankfurt, Germany
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19
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Moser EC, Hoffe SE, Frakes J, Aguilera TA, Karim M, Colbert LE, Moningi S, Tzeng CWD, Thall PF, Pant S, Bhutani MS, Brookes M, Holmlund J, Herman JM, Taniguchi CM. Adaptive dose optimization trial of stereotactic body radiation therapy (SBRT) with or without GC4419 (avasopasem manganese) in pancreatic cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.tps4670] [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
TPS4670 Background: Local progression causes up to 30% of deaths from pancreatic cancer (PC) and is also a significant source of morbidity. Stereotactic body radiotherapy (SBRT) offers the potential for improved therapeutic index over standard fractionation, but current regimens of 5 fractions of 5-7 Gy/fraction are constrained by nearby organ tolerance and offer only palliation without improving survival. Safe dose escalation may be necessary to improve SBRT efficacy. Avasopasem, a superoxide dismutase mimetic, selectively converts superoxide (O2•-) to hydrogen peroxide (H2O2) and oxygen. O2•-initiates normal tissue damage due to RT. Avasopasem is in a Phase 3 trial (NCT03689712) to reduce RT-induced oral mucositis in head and neck cancer, based on positive results in a randomized Phase 2 trial for that indication (Anderson, JCO 2019). Avasopasem improved the survival of mice receiving 8.5 Gy x 5 to the upper abdomen. Cancer cells are less tolerant to elevated H2O2, and more tolerant to elevated O2•-, than normal cells, and avasopasem demonstrated mechanism-dependent synergy with high dose-fraction RT in a human tumor xenograft with inducible expression of catalase (Sishc, AACR 2018). Thus, adding avasopasem to SBRT may increase both the efficacy and the safety of the latter. Methods: 48 patients with locally advanced PC, who have completed medically-indicated induction chemotherapy, are randomized 1:1 to placebo or avasopasem, 90 mg IV, prior to each of 5 consecutive daily (M-F) SBRT fractions. A phase I/II Late Onset Efficacy/ Toxicity tradeoff (LO-ET) based adaptive design adaptive model drives assignment of SBRT dose escalation in each arm based on a dual endpoint (Gr 3-4 GI toxicity or death; local stable disease or better) by 90 days post SBRT. The planned dose levels are 10, 11 and 12Gy x 5 fractions (BED10 = 100,112.5 and 132Gy, respectively) as an integrated boost to the gross tumor volume (GTV). Primary endpoint: Maximum tolerated dose of SBRT with avasopasem or placebo. Secondary endpoints progression-free survival, response rate, and acute (90 day) and late (12 month) radiation toxicity with avasopasem vs placebo. Exploratory correlative studies include ctDNA, tumor exome/transcriptome sequencing, and immune profiling. Clinical trial information: NCT03340974 .
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Affiliation(s)
| | - Sarah E. Hoffe
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jessica Frakes
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | | | | | | | | | | | - Shubham Pant
- The University of Texas MD Anderson Cancer Center, Houston, TX
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20
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Mizrahi JD, Moningi S, Nogueras-Gonzalez GM, Wolff RA, Javle MM, Varadhachary GR, Ho L, Fogelman DR, Raghav KP, Overman MJ, Crane CH, Herman JM, Koong AC, Koay EJ, Rogers JE, Pant S. Abstract B36: Maintenance chemotherapy after chemoradiation in patients with locally advanced pancreatic cancer. Cancer Res 2019. [DOI: 10.1158/1538-7445.panca19-b36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: More than half of patients (pts) with pancreatic cancer (PC) initially present with unresectable, locally advanced disease (LAPC). Data on management of these pts after systemic chemotherapy are scarce. Many clinicians utilize a strategy of induction chemotherapy followed by consolidative concurrent chemoradiation (CRT) for pts not progressing on initial chemotherapy. How to manage pts after CRT is controversial. We sought to evaluate the role of maintenance chemotherapy (MCT) after CRT in pts with LAPC.
Methods: We retrospectively analyzed LAPC pts treated with CRT at MD Anderson from 2005-2018. Pts who were taken for curative-intent surgery were excluded. Primary and secondary outcomes were median progression-free survival (mPFS) and median overall survival (mOS), respectively, as measured from the start date of CRT. Data were also obtained on pt demographics, response, and duration of induction chemotherapy as well as MCT regimens.
Results: We included 165 pts with LAPC treated with CRT in our analysis. Median age was 66 (range 39 – 84), and 97 (59%) pts were male. Median follow-up was 12.9 months. The median duration from initiation of induction chemotherapy to start of CRT was 4.4 months. Most pts (84%) received 1 line of induction chemotherapy prior to CRT. Ten pts (6%) did not receive induction chemotherapy and 17 pts (10%) received at least 2 lines prior to CRT. All but 9 pts (94%) developed disease progression (PD) after CRT, and 49 pts (33%) had PD within 3 months of CRT. On univariate analysis, PD on the induction chemotherapy regimen immediately prior to CRT was associated with shortened PFS (HR 2.46, p < 0.001) and OS (HR 2.96, p < 0.001) after CRT. Most pts (78%) did not receive MCT after CRT. 69% of pts who received MCT were male, compared to 56% of those who did not receive MCT. The percentages of pts who had PD on the chemotherapy regimen immediately prior to CRT in the MCT and no-MCT groups were 9% and 12%, respectively. Sixteen pts who received MCT were treated with either gemcitabine alone or a gemcitabine-containing regimen, while 14 pts received capecitabine monotherapy. On univariate analysis, the use of MCT after CRT was associated with prolonged mPFS (9.0 vs. 4.2 months, p = 0.01), but was not associated with an increase in mOS (15.5 vs. 12.5 months, p = 0.14). On multivariable analysis controlling for race, radiation dose, age, and whether there was progression on the chemotherapy regimen prior to CRT, the use of MCT was significantly associated with both prolonged PFS (HR 0.45, p < 0.001) and OS (HR 0.66, p = 0.047).
Conclusions: In this single-institution retrospective analysis of 165 pts with LAPC treated with CRT, treatment with post-CRT MCT was associated with a significant improvement in both PFS and OS as measured from the start date of CRT. Based on these results, MCT may be an appropriate option for pts with LAPC who have not progressed following consolidative CRT, and a prospective trial should be performed to better address this knowledge gap.
Citation Format: Jonathan D. Mizrahi, Shalini Moningi, Graciela M. Nogueras-Gonzalez, Robert A. Wolff, Milind M. Javle, Gauri R. Varadhachary, Linus Ho, David R. Fogelman, Kanwal P. Raghav, Michael J. Overman, Christopher H. Crane, Joseph M. Herman, Albert C. Koong, Eugene J. Koay, Jane E. Rogers, Shubham Pant. Maintenance chemotherapy after chemoradiation in patients with locally advanced pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2019 Sept 6-9; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2019;79(24 Suppl):Abstract nr B36.
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Affiliation(s)
| | - Shalini Moningi
- 1University of Texas MD Anderson Cancer Center, Houston, TX,
| | | | - Robert A. Wolff
- 1University of Texas MD Anderson Cancer Center, Houston, TX,
| | - Milind M. Javle
- 1University of Texas MD Anderson Cancer Center, Houston, TX,
| | | | - Linus Ho
- 1University of Texas MD Anderson Cancer Center, Houston, TX,
| | | | | | | | | | | | - Albert C. Koong
- 1University of Texas MD Anderson Cancer Center, Houston, TX,
| | - Eugene J. Koay
- 1University of Texas MD Anderson Cancer Center, Houston, TX,
| | - Jane E. Rogers
- 1University of Texas MD Anderson Cancer Center, Houston, TX,
| | - Shubham Pant
- 1University of Texas MD Anderson Cancer Center, Houston, TX,
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21
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Moningi S, Mesko S, Moreno AC, Ning MS, Aloia TA, Choi S, Jeter M, Martinez W, Recinos I, Nguyen T, Frenzel JC, French KE, Nguyen Q, Herman JM. Time driven activity-based costing methods used in radiation oncology clinics. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.27_suppl.79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
79 Background: Since 2010 The University of Texas MD Anderson Cancer Center (UTMDACC) has been using Time Driven Activity Based Costing (TDABC) to assist in tracking and quantifying changes made to clinical processes to improve efficiency of patient care delivery. Radiation Oncology (RO) providers have recently utilized this method to assist in the growing clinical patient volumes and increasing enrollment in clinical trials. UTMDACC contains disease specific multi-disciplinary centers with separate clinics for different disciplines. Resources are limited which can affect clinical providers’ ability to meet the needs of increasing patient volumes. Implementing efficient clinic work flow models will allow clinicians to provide excellent quality of clinical care even with limited resources. Methods: Standard disease-site specific note templates were created and implemented throughout the entire RO department. Additionally, standardized roles for medical assistants, residents, physician assistants (PAs), attending physicians and nurses were implemented to minimize duplication of responsibilities. Using TDABC methodology, process maps for pre and post implementation pathways were created to illustrate areas of change and possible benefit. Results: Process maps were compared for new consult and follow up and on treatment patient visits. Process times for these patient care visits were compared pre- and post-implementation of templates and clinical roles. Time savings of 110, 18 and 34 minutes were observed for consult visits, follow up visits and on-treatment visits when comparing current to baseline process maps. Conclusions: Standardization of note templates and roles for all members of the care team has led to improvements in process flow and efficiency in the RO clinic setting. Our findings suggest that further implementation of TDABC methodology by having all providers work at the top of their license could can improve clinical efficiency and patient care. Further metrics with a larger sample size is recommended to validate our results. [Table: see text]
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Affiliation(s)
| | | | | | - Matthew S. Ning
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Seungtaek Choi
- The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Melenda Jeter
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Iris Recinos
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thai Nguyen
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John C. Frenzel
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katy E. French
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Quynh Nguyen
- University of Texas MD Anderson Cancer Center, Houston, TX
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22
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Moningi S, Nguyen Q, Lin S, Jeter M, O'Reilly M, Chang J, Chen A, Allen P, Lu C, Tsao A, Mohan R, Liao Z. Phase II Trial of Intensity-Modulated Photon or Scanning Beam Proton Therapy Both with Simultaneous Integrated Boost Dose Escalation to the Gross Tumor Volume with Concurrent Chemotherapy for Stage II/III Non-Small Cell Lung Cancer - Interim Analysis. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.2416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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23
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Ludmir E, Moningi S, Mainwaring W, Miller A, Lin T, Jethanandani A, Espinoza A, Buszek S, Pinnix C, Das P, Woodward W, Guadagnolo B, Herman J, Koong A, Jagsi R, Fuller C, Holliday E. Women’s Representation among Lead Investigators of Clinical Trials in Oncology. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Moningi S, Ajani J, Badgwell B, Murphy M, Ikoma N, Ho J, Suh Y, Holliday E, Herman J, Minsky B, Koay E, Koong A, Krishnan S, Smith G, Taniguchi C, Das P. IMRT Reduces Acute Toxicity in Patients Treated with Preoperative Chemoradiation for Gastric Cancer. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.2046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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25
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Moningi S, Ludmir EB, Polamraju P, Williamson T, Melkun MM, Herman JD, Krishnan S, Koay EJ, Koong AC, Minsky BD, Smith GL, Taniguchi C, Das P, Holliday EB. Definitive hyperfractionated, accelerated proton reirradiation for patients with pelvic malignancies. Clin Transl Radiat Oncol 2019; 19:59-65. [PMID: 31517071 PMCID: PMC6734102 DOI: 10.1016/j.ctro.2019.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/23/2019] [Accepted: 08/26/2019] [Indexed: 12/25/2022] Open
Abstract
Introduction Pelvic reirradiation (re-RT) presents challenges due to concerns for late toxicity to tissues-at-risk including pelvic bone marrow (PBM). We routinely utilize a hyperfractionated, accelerated re-RT for recurrent rectal or anal cancer in the setting of prior radiation. We hypothesized that proton beam radiation (PBR) is uniquely suited to limit doses to pelvic non-target tissues better than photon-based approaches. Materials and methods All patients who received hyperfractionated, accelerated PBR re-RT to the pelvis from 2007 to 2017 were identified. Re-RT was delivered twice daily with a 6 h minimum interfraction interval at 1.5 Gray Relative Biological Effectiveness (Gy(RBE)) per fraction to a total dose of 39-45 Gy(RBE). Concurrent chemotherapy was given to all patients. Comparison photon plans were generated for dosimetric analysis. Dosimetric parameters compared using a matched-pair analysis and the Wilcoxon signed-rank test. Survival analysis was performed Kaplan Meier curves. Results Fifteen patients were identified, with a median prior pelvic RT dose of 50.4 Gy (range 25-80 Gy). Median time between the initial RT and PBRT re-RT was 4.7 years (range 1.0-36.1 years). In comparison to corresponding photon re-RT plans, PBR re-RT plans had lower mean PBM dose, and lower volume of PBM getting 5 Gy, 10 Gy, 20 Gy, and 30 Gy (p < 0.001, p < 0.001, p < 0.001, and p = 0.033, respectively).With median 13.9 months follow-up after PBR re-RT, five patients had developed local recurrences, and four patients had developed distant metastases. One-year overall survival following PBR re-RT was 67.5% and one-year progression free survival was 58.7%. No patients developed acute or late Grade 4 toxicity. Conclusion PBR re-RT affords improved sparing of PBM compared with photon-based re-RT. Clinically, PBR re-RT is well-tolerated. However, given modest control rates with definitive re-RT without subsequent surgical resection, a multidisciplinary approach should be favored in this setting when feasible.
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Affiliation(s)
- Shalini Moningi
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ethan B Ludmir
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Praveen Polamraju
- School of Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Tyler Williamson
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Marcella M Melkun
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Joseph D Herman
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sunil Krishnan
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Eugene J Koay
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Albert C Koong
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Bruce D Minsky
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Grace L Smith
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cullen Taniguchi
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Prajnan Das
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Emma B Holliday
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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26
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Holmlund J, Brookes M, Colbert LE, Moningi S, Bhutani MS, Katz MHG, Varadhachary GR, Thall PF, Herman JM, Taniguchi CM. Adaptive Dose Escalation Trial of Stereotactic Body Radiation Therapy (SBRT) in combination with GC4419 in pancreatic cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.tps4164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS4164 Background: Local progression causes up to 30% of deaths from pancreatic cancer (PC) and is also a significant source of morbidity. Stereotactic body radiotherapy (SBRT) offers the potential for improved therapeutic index over standard fractionation, but current regimens of 5-7 Gy/fraction x 5 are constrained by nearby organ tolerance and offer only palliation without improving survival. Safe dose escalation is necessary to improve SBRT efficacy. GC4419, a superoxide dismutase mimetic, selectively converts superoxide (O2•-) to hydrogen peroxide (H2O2) and oxygen. O2•-initiates normal tissue damage due to RT. GC4419 is in a Phase 3 trial (NCT03689712) to reduce RT-induced oral mucositis in head and neck cancer, based on positive results in a randomized Phase 2 trial for that indication (Anderson, ASCO 2018). GC4419 improved the survival of mice receiving 8.5 Gy x 5 to the upper abdomen. Cancer cells are less tolerant to elevated H2O2, and more tolerant to elevated O2•-, than normal cells, and GC4419 demonstrated mechanism-dependent synergy with high dose-fraction RT in a human tumor xenograft with inducible expression of catalase (Sishc, AACR 2018). Thus, adding GC4419 to SBRT may increase both the efficacy and the safety of the latter. Methods: 48 patients with localized, unresectable PC without frank duodenal invasion, who have received 3+ cycles of induction chemotherapy, are to be randomized 1:1 to placebo or GC4419, 90 mg IV, prior to each of 5 consecutive daily (M-F) SBRT fractions. A phase I/II Late Onset Efficacy/ Toxicity tradeoff (LO-ET) based adaptive design adaptive model drives SBRT dose escalation in each arm based on a dual endpoint (Gr 3-4 GI toxicity or death ;stable disease or better) by 90 days post SBRT. The planned dose levels are 10, 11 and 12Gy x 5 fractions (BED10=100,112.5 and 132Gy, respectively) as an integrated boost to the gross tumor volume (GTV). Primary endpoint: Maximum tolerated dose of SBRT with GC4419 or placebo. Exploratory endpoints include change in tumor radiographic resectability, correlative studies (ctDNA, exosomal DNA, tumor exome/transcriptome sequencing, immune profiling). Supported by Galera Therapeutics, Inc. Clinical trial information: NCT03340974.
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Moningi S, Ajani J, Badgwell B, Murphy M, Ikoma N, Ho J, Holliday E, Herman J, Minsky B, Koay E, Koong A, Krishnan S, Smith G, Taniguchi C, Das P. Can IMRT Reduce Lymphopenia in Patients Treated with Preoperative Chemoradiation for Gastric Cancer? Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/s0360-3016(19)30425-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bernard V, Aliru M, Moningi S, Ng SP, Garza S, Spelman AR, Liao Z, Michael L V, Herman J. Utilizing Artificial Intelligence to Increase Multi-Institutional Access to Clinical Trials. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/s0360-3016(19)30514-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Aliru M, Bernard V, Ng SP, Moningi S, Lindsay D, Berlind C, Ahern C, Holmes A, Edwards T, Smith B, Taniguchi C, Koay E, Das P, Holliday E, Herman J. Data Analytics Platform for Outcome Comparison of Patients Treated for Primary Pancreatic Cancer Using SBRT vs Conventional RT. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/s0360-3016(19)30527-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Moningi S, Ajani JA, Badgwell BD, Mansfield PF, Blum Murphy MA, Ikoma N, Ho J, Suh Y, Holliday EB, Herman JM, Minsky BD, Koay EJ, Koong A, Krishnan S, Smith GL, Taniguchi CM, Das P. The effect of IMRT on acute toxicity in patients with gastric cancer treated with preoperative chemoradiation. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.4_suppl.153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
153 Background: Two trials are currently investigating preoperative chemoradiation (CRT) for localized gastric adenocarcinoma. However, radiation therapy (RT) can be associated with relatively high rates of acute toxicity. Newer techniques, such as intensity modulated RT (IMRT), could reduce toxicity by reducing radiation dose to normal structures. Our goal was to compare rates of toxicity and toxicity-related events in patients treated with IMRT compared to 3D conformal RT (3DCRT). Methods: The records of 202 gastric cancer patients treated with preoperative intent RT at our institution from 1998-2018 were retrospectively reviewed. Demographic data, treatment details, acute and late toxicities (CTCAE 4.0 criteria), progression and survival data were recorded. Patients who had stage IV disease were excluded. Statistical analysis included descriptive statistics, Cox regression analysis, and Kaplan-Meier survival. Results: 54% were male and the median age was 63. 82 patients received 3DCRT and 120 patients received IMRT (median 45Gy, IQR, 45-45Gy in each group). 78% of patients in the 3DCRT group and 91% of patients in the IMRT group received neoadjuvant chemotherapy prior to RT. 99% of patients received concurrent chemotherapy. The rate of grade 3-4 acute toxicity was significantly lower in patients treated with IMRT compared to 3DCRT (53% vs. 73%, p = 0.004). The composite rate of toxicity-related events (hospitalization, feeding tube, IV rehydration, or RT break) was also significantly lower in patients treated with IMRT compared to 3DCRT (80% vs. 91%, p = 0.031). 72% of patients who received 3DCRT and 68% of patients who received IMRT underwent subsequent surgical resection. The 3-year OS rate was 58.1% for patients receiving IMRT and 60.2% for patients receiving 3DCRT (p = 0.649). The 3-year PFS rate was 47.5% for patients receiving IMRT and 52.7% for patients receiving 3DCRT (p = 0.486). Conclusions: Our study indicates a marked reduction in the rates of grade 3-4 acute toxicity and toxicity-associated events in patients treated with IMRT compared to 3DCRT. These findings suggest that IMRT should be considered as the radiation modality in patients treated with preoperative CRT for gastric cancer.
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Affiliation(s)
| | | | | | | | | | - Naruhiko Ikoma
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jennifer Ho
- Keck School of Medicine of USC, Los Angeles, CA
| | - Yelin Suh
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Albert Koong
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sunil Krishnan
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Grace L. Smith
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Prajnan Das
- University of Texas MD Anderson Cancer Center, Houston, TX
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Moningi S, Kuban D, Allen P, Kanke J, Master P, Anscher M, Chapin B, Choi S, Chun S, Chronowski G, Delclos M, Garg A, Mayo L, McGuire S, Nguyen Q, Pettaway C, Schlembach P, Shah S, Tang C, Hoffman K. Prospective Cancer Control and Patient-reported Quality of Life after Post-prostatectomy Salvage Radiation Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Colbert LE, Rebueno N, Moningi S, Beddar S, Sawakuchi GO, Herman JM, Koong AC, Das P, Holliday EB, Koay EJ, Taniguchi CM. Dose escalation for locally advanced pancreatic cancer: How high can we go? Adv Radiat Oncol 2018; 3:693-700. [PMID: 30370371 PMCID: PMC6200902 DOI: 10.1016/j.adro.2018.07.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 06/06/2018] [Revised: 07/25/2018] [Accepted: 07/26/2018] [Indexed: 12/17/2022] Open
Abstract
Purpose There are limited treatment options for locally advanced, unresectable pancreatic cancer (LAPC) and no likelihood of cure without surgery. Radiation offers an option for local control, but radiation dose has previously been limited by nearby bowel toxicity. Advances in on-board imaging and treatment planning may allow for dose escalation not previously feasible and improve local control. In preparation for development of clinical trials of dose escalation in LAPC, we undertook a dosimetric study to determine the maximum possible dose escalation while maintaining known normal tissue constraints. Methods and Materials Twenty patients treated at our institution with either SBRT or dose-escalated hypofractionated IMRT (DE-IMRT) were re-planned using dose escalated SBRT to 70 Gy in 5 fractions to the GTV and 40 Gy in 5 fractions to the PTV. Standard accepted organ at risk (OAR) constraints were used for planning. Descriptive statistics were generated for homogeneity, conformality, OAR's and GTV/PTV. Results Mean iGTV coverage by 50 Gy was 91% (±0.07%), by 60 Gy was 61.3% (±0.08%) and by 70 Gy was 24.4% (±0.05%). Maximum PTV coverage by 70 Gy was 33%. Maximum PTV coverage by 60 Gy was 77.5%. The following organ at risk (OAR) constraints were achieved for 90% of generated plans: Duodenum V20 < 30 cc, V30 < 3 cc, V35 < 1 cc; Small Bowel V20 < 15 cc, V30 < 1 cc, V35 < 0.1 cc; Stomach V20 < 20 cc, V30 < 2 cc, V35 < 1 cc. V40 < 0.5 cc was achieved for all OAR. Conclusions Dose escalation to 60 Gy is dosimetrically feasible with adequate GTV coverage. The identified constraints for OAR's will be used in ongoing clinical trials.
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Affiliation(s)
- Lauren E Colbert
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Neal Rebueno
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Shalini Moningi
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Sam Beddar
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Gabriel O Sawakuchi
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Joseph M Herman
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Albert C Koong
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Emma B Holliday
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Cullen M Taniguchi
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas
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Moningi S, Kuban D, Allen P, Choi S, Frank S, Nguyen Q, McGuire S, Skinner H, Schlembach P, Voong R, Hoffman K. Consideration of Patient Characteristics and Comorbidity in Selecting Candidates for Moderately Hypofractionated Radiation: Secondary Analysis From a Randomized Trial. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Moningi S, Amer A, Colbert L, Lee Y, Wolff R, Varadhachary G, Das P, Herman JM, Taniguchi C, Fleming JB, Katz MH, Crane C, Le O, Bhosale P, Tamm E, Koay EJ. (S022) Can Imaging-Based Biomarkers of Pancreatic Cancer be Used to Select Patients for Dose-Escalated Radiotherapy? Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.02.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Colbert LE, Moningi S, Chadha A, Amer A, Lee Y, Wolff RA, Varadhachary G, Fleming J, Katz M, Das P, Krishnan S, Koay EJ, Park P, Crane CH, Taniguchi CM. Dose escalation with an IMRT technique in 15 to 28 fractions is better tolerated than standard doses of 3DCRT for LAPC. Adv Radiat Oncol 2017; 2:403-415. [PMID: 29114609 PMCID: PMC5605283 DOI: 10.1016/j.adro.2017.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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: 11/21/2016] [Revised: 02/16/2017] [Accepted: 02/21/2017] [Indexed: 01/20/2023] Open
Abstract
Purpose To review acute and late toxicities after chemoradiation for locally advanced pancreatic ductal adenocarcinoma in patients who were treated with escalated dose radiation (EDR). Methods and materials Maximum Common Terminology Criteria for Adverse Events Version 4.0 acute toxicities (AT) during radiation and within 60 days after radiation were recorded for both acute gastrointestinal toxicity and overall toxicity (OT). Late toxicities were also recorded. EDR was generally delivered with daily image guidance and breath-hold techniques using intensity modulated radiation therapy (IMRT) planning. These were compared with patients who received standard dose radiation (SDR) delivered as 50.4 Gy in 28 fractions using 3-dimensional chemoradiation therapy planning. Results A total of 59 of 154 patients (39%) received EDR with biologically equivalent doses >70 Gy. The most frequent schedules were 63 Gy in 28 fractions (19 of 154 patients), 67.5 Gy in 15 fractions (10 of 154 patients), and 70 Gy in 28 fractions (15 of 154 patients). No grade 4 or grade 5 OT or late toxicities were reported. Rates of grade 3 acute gastrointestinal toxicity were significantly lower in patients who received EDR compared with SDR (1% vs 14%; P < .001). Similarly, rates of grade 3 OT were also lower for EDR compared with SDR (4% vs 16%; P = .004). The proportion of patients who experienced no AT was higher in the EDR group than the SDR group (36% vs 15%; P = .001). For EDR patients treated with IMRT, a lower risk of AT was associated with a later treatment year (P = .007), nonpancreatic head tumor location (P = .01), breath-hold (P = .002), 4-dimensional computed tomography (P = .003), computed tomography on rails (P = .002), and lower stomach V40 (P = .03). With a median time of 12 months (range, 1-79 months) from the start of radiation therapy to the last known follow-up in the EDR group, 51 of 59 patients (86%) had no late toxicity. Six of 59 EDR patients (10%) had either strictures or gastrointestinal bleeding that required intervention. No significant predictors of late toxicity were identified. Conclusion Overall acute and late toxicity rates were low with EDR using an IMRT technique with image guidance and respiratory gating.
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Affiliation(s)
- Lauren E Colbert
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Shalini Moningi
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Awalpreet Chadha
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Ahmed Amer
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Yeonju Lee
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Robert A Wolff
- Department of Medical Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Gauri Varadhachary
- Department of Medical Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Jason Fleming
- Department of Surgical Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Matthew Katz
- Department of Surgical Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Sunil Krishnan
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Eugene J Koay
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Peter Park
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, Texas
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Cullen M Taniguchi
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, Texas
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Kumar S, Patki A, Padhy N, Moningi S, Kulkarni D, Ramchandran G. A comparison of the effect of 0.9% saline versus balanced salt solution (plasma-lyte a) on acid base equilibrium, serum osmolarity and serum electrolytes in supratentorial neurosurgical procedures requiring craniotomy. Journal of Neuroanaesthesiology and Critical Care 2017. [DOI: 10.1055/s-0038-1646232] [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: 10/27/2022] Open
Affiliation(s)
- S. Kumar
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - A. Patki
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - N. Padhy
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - S. Moningi
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - D. Kulkarni
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - G. Ramchandran
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
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Colbert L, Moningi S, Chadha A, Wolff R, Varadhachary G, Fleming J, Katz M, Taniguchi C, Das P, Krishnan S, Koay E, Crane C. Dose Escalation With an Intensity Modulated Radiation Therapy Technique in 15 to 28 Fractions Is Better Tolerated Than Are Standard Doses of 3DCRT for LAPC. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.971] [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: 11/27/2022]
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Elnahal S, Rosati L, Moningi S, Hodgin M, Laheru D, Fishman E, Weiss M, Pawlik T, Wolfgang C, Herman J. Multidisciplinary Oncology Clinics Deliver Higher Value Care. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.2447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Jami P, Smith P, Moningi S, Moningi V, Martin SA, Rosencrance G, Reyes BJ. Compliance With Joint National Committee 7 Guidelines in Hypertension Management in a Teaching Institution. Am J Med Qual 2016; 22:251-8. [PMID: 17656729 DOI: 10.1177/1062860607303293] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM To assess compliance with Joint National Committee 7 (JNC 7) guidelines and evaluate target blood pressure (BP) goals among patients with hypertension. RESULTS Basic laboratory workup was completed on 75% of patients, and 71% received smoking cessation counseling. Overall BP goal achievement was 45.6%; it was 27.6% and 21.1% among diabetes and chronic kidney disease (CKD) patients, respectively. An average of 2.6 antihypertensive medications were prescribed per patient, with beta-blockers being the most frequently used, followed by thiazide diuretics and angiotensin-converting enzyme inhibitors (ACEIS). ACEIS or angiotensin receptor blockers (ARBs) were not prescribed for 16% of diabetics, 26% of chronic renal failure patients, or 41% of those with history of stroke. Among heart failure patients, 24.1% were not on ACEI or ARBs, and 20.7% were not receiving beta-blockers. CONCLUSIONS Certain aspects of JNC 7 are not well incorporated into clinical practice, especially among patients with coexisting diabetes and/or CKD.
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Affiliation(s)
- Prasuna Jami
- Department of Internal Medicine, West Virginia University, Charleston, USA
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Rosati LM, Moningi S, Hacker-Prietz A, Laheru D, Zheng L, De Jesus-Acosta A, Le DT, Moore JA, Fishman EK, Raman SP, McNutt TR, Pawlik TM, Eckhauser FE, Weiss MJ, Herman JM. A prospective study evaluating stereotactic body radiation therapy in unresectable, recurrent, or residual pancreatic adenocarcinoma. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.454] [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
454 Background: The purpose of this prospective, non-randomized phase II single-institution study was to evaluate if local control can be achieved with reasonable acute and late GI toxicity using fractionated SBRT in patients with unresectable, recurrent, or residual locally advanced pancreatic cancer (LAPC). Methods: A total of 24 patients with LAPC were enrolled from June 2013 to August 2014. Eligibility required stability after induction chemotherapy or residual disease or local failure after surgery. Induction chemotherapy regimens consisted of: (1) gemcitabine alone (8%); (2) gemcitabine-based regimens (17%); (3) FOLFIRINOX-based regimens (63%); or (4) combination regimens (13%). Chemotherapy was discontinued one week prior to SBRT. Patients received a median cumulative dose of 33 Gy in 5 fractions (5-6.6 Gy/fraction). Patients were permitted to resume chemotherapy one week post-SBRT. Toxicity was assessed using the NCI CTCAE version 4.0. Results: Of the 24 patients, 58% were male and 50% had tumors in the head of the pancreas. Median age at diagnosis was 66.8 years, and median follow-up from the date of diagnosis was 11.9 months (range, 7.4-29.7 months). There have not been any acute or late grade ≥ 2 gastritis, enteritis, fistula, or ulcer toxicities (primary endpoint). Median OS has not yet been reached, median LPFS was 19.3 months (95% CI, 12.3-14.8), median DMFS was 13.6 months (95% CI, 9.2-17.9) and median PFS was 13.6 months (95% CI, 13.5-25.2). Plasma CA 19-9 level was non-significantly reduced after SBRT, displaying a -9.15 average percent change from baseline (median time after SBRT, 1.2 months). FFLP at 1 year was 83.9%. Eight (33%) patients underwent successful surgery following SBRT, with rates of both margin- and node-negative resection being 75%. Conclusions: Chemotherapy followed by fractionated SBRT results in favorable local control and survival with minimal acute and late GI toxicity. A notable proportion of patients initially deemed unresectable underwent successful resection. This study suggests that SBRT can be safely given following more aggressive multiagent chemotherapy in patients with LAPC. Clinical trial information: NCT01781728.
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Affiliation(s)
- Lauren M. Rosati
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shalini Moningi
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Amy Hacker-Prietz
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dan Laheru
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ana De Jesus-Acosta
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dung T Le
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph A. Moore
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elliot K. Fishman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Siva P. Raman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Todd R. McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Fred E Eckhauser
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew J. Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Mian O, Chen L, Narang A, Leal J, Rowe S, Rao A, Moningi S, Rosati L, Herman J. Total Lesion Glycolysis as a Predictor of Pathologic Outcomes Locally Advanced and Borderline Resectable Patients Undergoing Surgery After Preoperative Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2015. [DOI: 10.1016/j.ijrobp.2015.07.1019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Assadi R, Rosati L, Moningi S, Hacker-Prietz A, Laheru D, Zheng L, De Jesus-Acosta A, Le D, Kelly G, Moore J, Jackson J, Fishman E, Raman S, McNutt T, Pawlik T, Hirose K, Eckhauser F, Weiss M, Herman J. A Prospective Study Evaluating Stereotactic Body Radiation Therapy in Unresectable Recurrent or Residual Pancreatic Adenocarcinoma. Int J Radiat Oncol Biol Phys 2015. [DOI: 10.1016/j.ijrobp.2015.07.372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kishan A, Moningi S, Kumar R, Ancukiewicz M, Ahuja N, Gearhart S, Efron J, Herman J, Hong T. Standard Fractionation External Beam Radiation Therapy With and Without Intraoperative Radiation Therapy for Patients With Locally Recurrent Rectal Cancer. Int J Radiat Oncol Biol Phys 2015. [DOI: 10.1016/j.ijrobp.2015.07.918] [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: 11/24/2022]
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Rao AD, Chang DT, Parekh A, Rosati LM, Moningi S, Blackford A, Hacker-Prietz A, Wild AT, Zheng L, Weiss M, Pawlik TM, Asrari F, Fisher G, Laheru DA, Wolfgang CL, Koong AC, Herman JM. WITHDRAWN: Multiplex proximity ligation assay to identify a biomarker panel for prognosis in unresectable pancreatic cancer patients treated with stereotactic body radiation therapy. Int J Radiat Oncol Biol Phys 2015. [DOI: 10.1016/j.ijrobp.2015.08.042] [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: 11/15/2022]
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Wild AT, Dholakia AS, Fan KY, Kumar R, Moningi S, Rosati LM, Laheru DA, Zheng L, De Jesus-Acosta A, Ellsworth SG, Hacker-Prietz A, Voong KR, Tran PT, Hruban RH, Pawlik TM, Wolfgang CL, Herman JM. Efficacy of platinum chemotherapy agents in the adjuvant setting for adenosquamous carcinoma of the pancreas. J Gastrointest Oncol 2015; 6:115-25. [PMID: 25830031 DOI: 10.3978/j.issn.2078-6891.2014.091] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/11/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Pancreatic adenosquamous carcinoma (PASC) accounts for only 1-4% of all exocrine pancreatic cancers and carries a particularly poor prognosis. This retrospective study was performed to determine whether inclusion of a platinum agent as part of adjuvant therapy is associated with improved survival in patients with resected PASC. METHODS Records of all patients who underwent pancreatic resection at Johns Hopkins Hospital from 1986 to 2012 were reviewed to identify those with PASC. Multivariable Cox proportional hazards modeling was used to assess for significant associations between patient characteristics and survival. RESULTS In total, 62 patients (1.1%) with resected PASC were identified among 5,627 cases. Median age was 68 [interquartile range (IQR), 57-77] and 44% were female. Multivariate analysis revealed that, among all patients (n=62), the following factors were independently predictive of poor survival: lack of adjuvant therapy [hazard ratio (HR) =3.6; 95% confidence interval (CI), 1.8-7.0; P<0.001], margin-positive resection (HR =3.5; 95% CI, 1.8-6.8; P<0.001), lymph node involvement (HR =3.5; 95% CI, 1.5-8.2; P=0.004), and age (HR =1.0; 95% CI, 1.0-1.1; P=0.035). There were no significant differences between patients who did and did not receive adjuvant therapy following resection (all P>0.05). A second multivariable model included only those patients who received adjuvant therapy (n=39). Lack of inclusion of a platinum agent in the adjuvant regimen (HR =2.4; 95% CI, 1.0-5.8; P=0.040) and larger tumor diameter (HR =1.3; 95% CI, 1.0-1.6; P=0.047) were independent predictors of inferior survival. CONCLUSIONS Addition of a platinum agent to adjuvant regimens for resected PASC may improve survival among these high-risk patients, though collaborative prospective investigation is needed.
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Affiliation(s)
- Aaron T Wild
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Avani S Dholakia
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Katherine Y Fan
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Rachit Kumar
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Shalini Moningi
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Lauren M Rosati
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Daniel A Laheru
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Lei Zheng
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Ana De Jesus-Acosta
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Susannah G Ellsworth
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Amy Hacker-Prietz
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Khinh R Voong
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Phuoc T Tran
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Ralph H Hruban
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Timothy M Pawlik
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Christopher L Wolfgang
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Joseph M Herman
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
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Moningi S, Walker AJ, Malayeri AA, Rosati LM, Gearhart SL, Efron JE, Wick EC, Azad NS, Armour EP, Le Y, Herman JM, Shin EJ. Analysis of fiducials implanted during EUS for patients with localized rectal cancer receiving high-dose rate endorectal brachytherapy. Gastrointest Endosc 2015; 81:765-769.e1. [PMID: 25708766 PMCID: PMC4629841 DOI: 10.1016/j.gie.2014.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 11/04/2014] [Indexed: 12/11/2022]
Affiliation(s)
- Shalini Moningi
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amanda J. Walker
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ashkan A. Malayeri
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lauren M. Rosati
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Susan L. Gearhart
- Department of Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathan E. Efron
- Department of Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth C. Wick
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nilofer S. Azad
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elwood P. Armour
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yi Le
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph M. Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eun Ji Shin
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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He J, Moningi S, Blair AB, Zaki A, Laheru DA, Cameron JL, Pawlik TM, Weiss MJ, Wolfgang CL, Herman JM. Surgical outcomes of patients with pancreatic cancer treated with stereotactic body radiation therapy. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.3_suppl.341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
341 Background: The surgical outcome of patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BRPC/LAPC) treated with stereotactic body radiation therapy (SBRT) is unclear. Methods: A comparative study was performed to determine if surgical outcomes were different among patients receiving neoadjuvant SBRT vs chemoradiation therapy (CRT) vs chemotherapy only. Results: Between 2011 and 2014, 29 patients with BR/LA-PDAC underwent neoadjuvant chemotherapy and SBRT (6.6 Gy x 5 fractions) followed by pancreatectomy. Eighteen of 29 patients (62%) had LAPC. Their outcomes were compared with 82 patients who received neoadjuvant CRT and 26 patients who received neoadjuvant chemotherapy only (Table). When compared to neoadjuvant CRT and chemo only, the neoadjuvant SBRT group had a higher R0 resection rate (90% vs 84% vs 62%, p=0.02) and vascular resection rate (41% vs 13% vs 31%, p=0.005), respectively. Although the vascular resection and complication rates (Clavien grade 3 or above) were higher in the neoadjuvant SBRT group, no in-hospital mortality was encountered. In the SBRT group, the complete pathological response rate (21%) was higher than that of the other groups (4% and 0% respectively, p<0.001). Survival will be updated later as the current median postoperative follow-up is 6 months in the SBRT group. Conclusions: Neoadjuvant chemotherapy and SBRT is associated with improved surgical outcomes and pathologic complete response rates in selected patients with BRPC/LAPC. Longer follow-up is needed to determine its impact on survival. [Table: see text]
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Affiliation(s)
- Jin He
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | - Daniel A. Laheru
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | | | | | | | | | - Joseph M. Herman
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
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Moningi S, Dholakia AS, Raman SP, Blackford A, Cameron JL, Le DT, De Jesus-Acosta AMC, Hacker-Prietz A, Rosati LM, Assadi RK, Dipasquale S, Pawlik TM, Zheng L, Weiss MJ, Laheru DA, Wolfgang CL, Herman JM. The Role of Stereotactic Body Radiation Therapy for Pancreatic Cancer: A Single-Institution Experience. Ann Surg Oncol 2015; 22:2352-8. [PMID: 25564157 DOI: 10.1245/s10434-014-4274-5] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) is a promising option for patients with pancreatic cancer (PCA); however, limited data support its efficacy. This study reviews our institutional experience of SBRT in the treatment of locally advanced (LAPC) and borderline resectable (BRPC) PCA. METHODS Charts of all PCA patients receiving SBRT at our institution from 2010 to 2014 were reviewed. Most patients received pre-SBRT chemotherapy. Primary endpoints included overall survival (OS) and local progression-free survival (LPFS). Patients received a total dose of 25-33 Gy in five fractions. RESULTS A total of 88 patients were included in the analysis, 74 with LAPC and 14 with BRPC. The median age at diagnosis was 67.2 years, and median follow-up from date of diagnosis for LAPC and BRPC patients was 14.5 and 10.3 months, respectively. Median OS from date of diagnosis was 18.4 months (LAPC, 18.4 mo; BRPC, 14.4 mo) and median PFS was 9.8 months (95 % CI 8.0-12.3). Acute toxicity was minimal with only three patients (3.4 %) experiencing acute grade ≥3 toxicity. Late grade ≥2 gastrointestinal toxicity was seen in five patients (5.7 %). Of the 19 patients (21.6 %) who underwent surgery, 79 % were LAPC patients and 84 % had margin-negative resections. CONCLUSIONS Chemotherapy followed by SBRT in patients with LAPC and BRPC resulted in minimal acute and late toxicity. A large proportion of patients underwent surgical resection despite limited radiographic response to therapy. Further refinements in the integration of chemotherapy, SBRT, and surgery might offer additional advancements toward optimizing patient outcomes.
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Affiliation(s)
- Shalini Moningi
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Moningi S, Walker AJ, Hsu CC, Reese JB, Wang JY, Fan KY, Rosati LM, Laheru DA, Weiss MJ, Wolfgang CL, Pawlik TM, Herman JM. Correlation of clinical stage and performance status with quality of life in patients seen in a pancreas multidisciplinary clinic. J Oncol Pract 2015; 11:e216-21. [PMID: 25563703 DOI: 10.1200/jop.2014.000976] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [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
INTRODUCTION The objectives of this study were to evaluate quality of life (QoL) in patients presenting to the Johns Hopkins Pancreas Multidisciplinary Clinic (PMDC), and to examine associations between disease status, performance status, and QoL in order to identify patient subgroups that are most at risk for reduced QoL. PATIENTS AND METHODS Data from 77 patients were evaluated. At initial presentation, disease and performance status were assessed, as well as QoL, which was obtained with the European Organisation for Research and Treatment of Cancer QLQ-PAN26 questionnaire. Statistical analyses examined associations between QoL, disease status, and performance status. RESULTS Digestive symptoms (P < .003) significantly differed by pancreatic disease status (resectable, resected, locally advanced, and metastatic). Patients with a worse performance status, defined as Eastern Cooperative Oncology Group ≥ 1, were more likely to report symptomatic pancreatic pain (P = .001), digestive symptoms (P = .017), cachexia (P = .004), and ascites (P < .001) compared with patients with a performance status of 0. The majority (92%) of patients reported a significant fear of future health problems, regardless of disease status or performance status. CONCLUSION Although several measures of QoL have been observed in all patients, certain measures appear to correlate specifically with worse disease status. Therefore, routine assessment of QoL is suggested in order to guide treatment decisions. Further investigation on optimizing the use of QoL measures and patient-reported outcomes to better tailor management is warranted.
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Affiliation(s)
- Shalini Moningi
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
| | - Amanda J Walker
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
| | - Charles C Hsu
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
| | - Jennifer Barsky Reese
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
| | - Jing-Ya Wang
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
| | - Katherine Y Fan
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
| | - Lauren M Rosati
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
| | - Daniel A Laheru
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
| | - Matthew J Weiss
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
| | - Christopher L Wolfgang
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
| | - Timothy M Pawlik
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
| | - Joseph M Herman
- Johns Hopkins University School of Medicine, Baltimore, MD; and University of California, San Francisco, San Francisco, CA
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Moningi S, Marciscano AE, Rosati LM, Ng SK, Teboh Forbang R, Jackson J, Chang DT, Koong AC, Herman JM. Stereotactic body radiation therapy in pancreatic cancer: the new frontier. Expert Rev Anticancer Ther 2014; 14:1461-75. [PMID: 25183386 DOI: 10.1586/14737140.2014.952286] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Pancreatic cancer (PCA) remains a disease with a poor prognosis. The majority of PCA patients are unable to undergo surgical resection, which is the only potentially curative option at this time. A combination of chemotherapy and chemoradiation (CRT) are standard options for patients with locally advanced, unresectable disease, however, local control and patient outcomes remains poor. Stereotactic body radiation therapy (SBRT) is an emerging treatment option for PCA. SBRT delivers potentially ablative doses to the pancreatic tumor plus a small margin over a short period of time. Early studies with single-fraction SBRT demonstrated excellent tumor control with high rates of toxicity. The implementation of SBRT (3-5 doses) has demonstrated promising outcomes with favorable tumor control and toxicity rates. Herein we discuss the evolving role of SBRT in PCA treatment.
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Affiliation(s)
- Shalini Moningi
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, 401 N. Broadway, Weinberg Suite 1440, Baltimore, MD 21231, USA
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