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Tse V, Sillanpaa J, Minn AY, Teng M, Xiaoyang F, Gillis A, Millender L, Sheridan W, Wara W. Glomus tumors treated with stereotactic radiosurgery: A retrospective study. J Radiosurg SBRT 2017; 5:73-81. [PMID: 29296465 PMCID: PMC5675510] [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] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/09/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Glomus tumors are difficult to manage surgically because they are vascular tumors that are topographically associated with important vascular and neuronal structures. Hence, there is a strong risk of incomplete resection and a high morbidity rate. In addition, they grow slowly. Recent treatments have increasingly involved a combination of surgical resection and radiosurgery. We present our experience in treating glomus tumors of the skull base with stereotactic radiosurgery as an upfront therapy. METHODS We analyzed data from 13 consecutive patients with glomus tumors that were initially treated with stereotactic radiosurgery in our institute from February 2010 to April 2012. The tumor control rate, resolution of symptoms, and the complication rate were tabulated. RESULTS All patients were female with a median age of 63 (mean 62.7+/-14.6 years). The median treatment dose was 25.8 Gy (27.6 Gy +/- 9.5 Gy) and the median tumor volume 10.4 mL (9.2 +/- 6.5). The median follow-up was 47.4 months (51.8+/-11.2 months, range 31-74). The tumor control rate was 92.3%; 46.7% of the patients had noticeable tumor shrinkage. This happened at a median interval of 17 months (18.7+/-6.8) after treatment. Most patients with tinnitus had resolution of their symptoms (87.5%). Four patients presented with new symptoms and four patients with worsening of pre-existing symptoms. The time course of symptomatic improvement followed that of tumor size reduction. However, there was no statistical correlation between the amount of tumor reduction and symptomatic relief. CONCLUSION Stereotactic radiosurgery (SRS) is an effective upfront treatment option in the management of glomus tumors.
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Affiliation(s)
- Victor Tse
- Department of Radiation Oncology, Kaiser Permanente Comprehensive Cancer Treatment Center, 220 Oyster Point Blvd., South San Francisco, CA 94080, USA
- Department of Neurosurgery, Kaiser Permanente Northern California Neuroscience Center, Tower Building 3rd Floor, 1150 Veterans Blvd., Redwood City, CA 94063, USA
| | - Jussi Sillanpaa
- Department of Radiation Oncology, Kaiser Permanente Comprehensive Cancer Treatment Center, 220 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Ann Y Minn
- Department of Radiation Oncology, Kaiser Permanente Comprehensive Cancer Treatment Center, 220 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Ming Teng
- Department of Radiation Oncology, Kaiser Permanente Comprehensive Cancer Treatment Center, 220 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Fu Xiaoyang
- Department of Radiation Oncology, Kaiser Permanente Comprehensive Cancer Treatment Center, 220 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Amy Gillis
- Department of Radiation Oncology, Kaiser Permanente Comprehensive Cancer Treatment Center, 220 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Laura Millender
- Department of Radiation Oncology, Kaiser Permanente Comprehensive Cancer Treatment Center, 220 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - William Sheridan
- Department of Radiation Oncology, Kaiser Permanente Comprehensive Cancer Treatment Center, 220 Oyster Point Blvd., South San Francisco, CA 94080, USA
- Department of Neurosurgery, Kaiser Permanente Northern California Neuroscience Center, Tower Building 3rd Floor, 1150 Veterans Blvd., Redwood City, CA 94063, USA
| | - William Wara
- Department of Radiation Oncology, Kaiser Permanente Comprehensive Cancer Treatment Center, 220 Oyster Point Blvd., South San Francisco, CA 94080, USA
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Dhruva A, Aouizerat BE, Cooper B, Paul SM, Dodd M, West C, Wara W, Lee K, Dunn LB, Langford DJ, Merriman JD, Baggott C, Cataldo J, Ritchie C, Kober KM, Leutwyler H, Miaskowski C. Cytokine gene associations with self-report ratings of morning and evening fatigue in oncology patients and their family caregivers. Biol Res Nurs 2014; 17:175-84. [PMID: 24872120 DOI: 10.1177/1099800414534313] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The purpose of this study was to evaluate for differences in variations in pro- and anti-inflammatory cytokine genes between participants who were classified as having low and high levels of morning and evening fatigue and to evaluate for differences in phenotypic characteristics between these two groups. In a sample of 167 oncology outpatients with breast, prostate, lung, or brain cancer and 85 of their family caregivers, growth mixture modeling was used to identify latent classes of individuals based on ratings of morning and evening fatigue obtained prior to, during, and for 4 months following completion of radiation therapy. Differences in single nucleotide polymorphisms and haplotypes in 15 cytokine genes were evaluated between the latent classes. Multiple logistic regression was used to assess the effect of phenotypic and genotypic characteristics on morning and evening fatigue class membership. Associations were found between morning fatigue and number of comorbidities as well as variations in tumor necrosis factor alpha (TNFA) rs1800629 and rs3093662. Evening fatigue was associated with caring for children at home and variations in interleukin 4 (IL4) rs2243248 and TNFA rs2229094. Younger age and lower performance status were associated with both morning and evening fatigue. These findings suggest that inflammatory mediators are associated with the development of morning and evening fatigue. However, because different phenotypic characteristics and genomic markers are associated with diurnal variations in fatigue, morning and evening fatigue may be distinct but related symptoms.
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Affiliation(s)
- Anand Dhruva
- School of Medicine, University of California, San Francisco, CA, USA
| | - Bradley E Aouizerat
- School of Nursing, University of California, San Francisco, CA, USA Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - Bruce Cooper
- School of Nursing, University of California, San Francisco, CA, USA
| | - Steven M Paul
- School of Nursing, University of California, San Francisco, CA, USA
| | - Marylin Dodd
- School of Nursing, University of California, San Francisco, CA, USA
| | - Claudia West
- School of Nursing, University of California, San Francisco, CA, USA
| | | | - Kathryn Lee
- School of Nursing, University of California, San Francisco, CA, USA
| | - Laura B Dunn
- School of Medicine, University of California, San Francisco, CA, USA
| | - Dale J Langford
- School of Nursing, University of California, San Francisco, CA, USA
| | - John D Merriman
- School of Nursing, University of California, San Francisco, CA, USA
| | | | - Janine Cataldo
- School of Nursing, University of California, San Francisco, CA, USA
| | - Christine Ritchie
- School of Medicine, University of California, San Francisco, CA, USA
| | - Kord M Kober
- School of Nursing, University of California, San Francisco, CA, USA
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Dhruva A, Aouizerat BE, Cooper B, Paul SM, Dodd M, West C, Wara W, Lee K, Dunn LB, Langford DJ, Merriman JD, Baggott C, Cataldo J, Ritchie C, Kober K, Leutwyler H, Miaskowski C. Differences in morning and evening fatigue in oncology patients and their family caregivers. Eur J Oncol Nurs 2013; 17:841-8. [PMID: 24012189 PMCID: PMC3867806 DOI: 10.1016/j.ejon.2013.06.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 06/10/2013] [Accepted: 06/21/2013] [Indexed: 01/13/2023]
Abstract
PURPOSE OF THE RESEARCH To identify distinct latent classes of individuals based on ratings of morning and evening fatigue; evaluate for differences in phenotypic characteristics, as well as symptom and quality of life scores, among these latent classes; and evaluate for an overlap in morning and evening fatigue class membership. PATIENTS AND METHODS In a sample of 167 oncology outpatients and 85 of their FCs, growth mixture modeling was used to identify distinct latent classes based on ratings of morning and evening fatigue obtained before, during, and after radiation therapy. Analyses of variance and Chi Square analyses were used to evaluate for differences among the morning and evening fatigue latent classes. RESULTS Three distinct latent classes for morning fatigue were identified. Participants in the High Morning Fatigue class (47%) were younger and had lower functional status. Three distinct latent classes for evening fatigue were identified. Participants in the High Evening Fatigue class (61%) were younger, more likely to be female, more likely to have children at home, and more likely to be a FC. Only 10.3% of participants were classified in both the Very Low Morning and Low Evening Fatigue classes and 41.3% were classified in both the High Morning and High Evening Fatigue classes. CONCLUSIONS Different characteristics were associated with morning and evening fatigue, which suggests that morning and evening fatigue may be distinct but related symptoms. Additional research is needed to elucidate the mechanisms that may underlie diurnal variability in fatigue.
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Affiliation(s)
- Anand Dhruva
- School of Medicine, University of California, San Francisco, CA, USA
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Dhruva A, Paul SM, Cooper BA, Lee K, West C, Aouizerat BE, Dunn LB, Swift PS, Wara W, Miaskowski C. A longitudinal study of measures of objective and subjective sleep disturbance in patients with breast cancer before, during, and after radiation therapy. J Pain Symptom Manage 2012; 44:215-28. [PMID: 22795049 PMCID: PMC3414693 DOI: 10.1016/j.jpainsymman.2011.08.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 07/30/2011] [Accepted: 09/01/2011] [Indexed: 11/19/2022]
Abstract
CONTEXT Sleep disturbance is a significant problem in oncology patients. OBJECTIVES To examine how actigraphy and self-report ratings of sleep disturbance changed over the course of and after radiation therapy (RT); investigate whether specific patient, disease, and symptom characteristics predicted the initial levels and/or the characteristics of the trajectories of sleep disturbance; and compare predictors of subjective and objective sleep disturbance. METHODS Patients (n=73) completed self-report questionnaires that assessed sleep disturbance, fatigue, depressive symptoms, anxiety, and pain before the initiation of RT through four months after the completion of RT. Wrist actigraphy was used as the objective measure of sleep disturbance. Hierarchical linear modeling was used for data analyses. RESULTS Mean wake after sleep onset was 11.9% and mean total score on the General Sleep Disturbance Scale was 45. More than 85% of the patients had an abnormally high number of nighttime awakenings. Substantial interindividual variability was found for both objective and subjective measures of sleep disturbance. Body mass index predicted baseline levels of objective sleep disturbance. Comorbidity, evening fatigue, and depressive symptoms predicted baseline levels of subjective sleep disturbance, and depressive symptoms predicted the trajectory of subjective sleep disturbance. CONCLUSION Different variables predicted sleep disturbance using subjective and objective measures. The slightly elevated wake after sleep onset found may be an underestimation of the degree of sleep disturbance when it is evaluated in the context of the high number of nighttime awakenings and patient's perception of poor sleep quality and quantity.
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Affiliation(s)
- Anand Dhruva
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Garrett K, Dhruva A, Koetters T, West C, Paul SM, Dunn LB, Aouizerat BE, Cooper BA, Dodd M, Lee K, Wara W, Swift P, Miaskowski C. Differences in sleep disturbance and fatigue between patients with breast and prostate cancer at the initiation of radiation therapy. J Pain Symptom Manage 2011; 42:239-50. [PMID: 21454042 PMCID: PMC3145041 DOI: 10.1016/j.jpainsymman.2010.11.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 10/23/2010] [Accepted: 11/06/2010] [Indexed: 11/15/2022]
Abstract
CONTEXT Little is known about the occurrence and severity of sleep disturbance and fatigue between patients with common cancer diagnoses. OBJECTIVES Study purposes were to evaluate for differences in the occurrence rates of sleep disturbances and fatigue; evaluate for differences in the severity of sleep disturbance using both subjective and objective measures; and evaluate for differences in the severity of self-reported fatigue in patients with breast and prostate cancer at the initiation of radiation therapy (RT). METHODS Patients with breast (n=78) and prostate (n=82) cancer were evaluated before the initiation of RT using the Pittsburgh Sleep Quality Index, General Sleep Disturbance Scale, Lee Fatigue Scale, and wrist actigraphy. Differences in sleep disturbance and fatigue between groups were evaluated using independent sample t-tests and Chi-square analyses. RESULTS Occurrence rates for sleep disturbance (P<0.0001) and fatigue (P=0.03) were significantly higher in patients with breast compared with prostate cancer. Patients with breast cancer self-reported significantly higher levels of sleep disturbance (P=0.008) and fatigue (P=0.005) than patients with prostate cancer. However, using actigraphy, patients with prostate cancer had poorer sleep efficiency (P=0.02) than patients with breast cancer. CONCLUSION Based on self-report, patients with breast cancer experience sleep disturbance more frequently and with greater severity than patients with prostate cancer. Objective measures of sleep disturbance suggest that prostate cancer patients have more severe sleep disturbance than breast cancer patients. All the patients experienced poor sleep quality and fatigue, which suggests that oncology patients need to be assessed for these symptoms.
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Affiliation(s)
- Kristin Garrett
- School of Nursing, University of California, San Francisco, California 94143-0610, USA
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Carney S, Koetters T, Cho M, West C, Paul SM, Dunn L, Aouizerat BE, Dodd M, Cooper B, Lee K, Wara W, Swift P, Miaskowski C. Differences in sleep disturbance parameters between oncology outpatients and their family caregivers. J Clin Oncol 2011; 29:1001-6. [PMID: 21282549 PMCID: PMC3068050 DOI: 10.1200/jco.2010.30.9104] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [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: 06/06/2010] [Accepted: 11/30/2010] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This study compared the occurrence rates for and severity ratings of sleep disturbance in patient-family caregiver (FC) dyads. PATIENTS AND METHODS In total, 102 dyads were recruited from two radiation therapy (RT) departments. Patients and their FCs completed the Pittsburgh Sleep Quality Index (PSQI) and the General Sleep Disturbance Scale (GSDS) and wore wrist actigraphs to obtain subjective and objective measures of the occurrence and severity of sleep disturbance at the initiation of RT. Match paired t tests were used to evaluate for dyadic differences. RESULTS No differences were found in the occurrence of clinically significant levels of sleep disturbance between patients and their FCs that ranged between 40% and 50% using subjective and objective measures. Few differences were found in the severity of any of the sleep-wake parameters between patients and FCs using both the subjective and objective measures of sleep disturbance. CONCLUSION The findings from this study suggest that patients with cancer and their FCs experience similar levels of sleep disturbance and that both groups could benefit from interventions that aim to promote restful sleep. In addition to routine and systematic assessment of sleep disturbance by oncology clinicians, interventions are needed that take into account the specific needs of the patient and the FC as well as the potential for partners' sleep patterns to influence one another.
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Affiliation(s)
- Sara Carney
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - Theresa Koetters
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - Maria Cho
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - Claudia West
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - Steven M. Paul
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - Laura Dunn
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - Bradley E. Aouizerat
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - Marylin Dodd
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - Bruce Cooper
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - Kathryn Lee
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - William Wara
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - Patrick Swift
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
| | - Christine Miaskowski
- From the Schools of Nursing and Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco; and Alta Bates Comprehensive Cancer Center, Berkeley, CA
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Dunn LB, Aouizerat BE, Cooper BA, Dodd M, Lee K, West C, Paul SM, Wara W, Swift P, Miaskowski C. Trajectories of anxiety in oncology patients and family caregivers during and after radiation therapy. Eur J Oncol Nurs 2011; 16:1-9. [PMID: 21324418 DOI: 10.1016/j.ejon.2011.01.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 01/06/2011] [Accepted: 01/12/2011] [Indexed: 11/17/2022]
Abstract
PURPOSE Anxiety is common in patients undergoing radiation therapy (RT) and in their family caregivers (FCs). Little is known about individual differences in anxiety trajectories during and after RT. This study aimed to identify distinct latent classes of oncology patients and their FCs based on self-reported anxiety symptoms from the beginning to four months after the completion of RT. METHOD Using growth mixture modeling (GMM), longitudinal changes in Spielberger State Anxiety Inventory (STAI-S) scores among 167 oncology outpatients with breast, prostate, lung, or brain cancer and 85 FCs were evaluated to determine distinct anxiety symptom profiles. STAI-S scores were assessed just prior to, throughout the course of, and for four months following RT (total of 7 assessments). Baseline trait anxiety and depressive symptoms (during and after RT) were also assessed. RESULTS The GMM analysis identified three latent classes of oncology patients and FCs with distinct trajectories of state anxiety: Low Stable (n = 93, 36.9%), Intermediate Decelerating (n = 82, 32.5%), and High (n = 77, 30.6%) classes. Younger participants, women, ethnic minorities, and those with children at home were more likely to be classified in the High anxiety class. Higher levels of trait anxiety and depressive symptoms, at the initiation of RT, were associated with being in the High anxiety class. CONCLUSIONS Subgroups of patients and FCs with high, intermediate, and low mean levels of anxiety during and after RT were identified with GMM. Additional research is needed to better understand the heterogeneity of symptom experiences as well as comorbid symptoms in patients and FCs.
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Affiliation(s)
- Laura B Dunn
- School of Medicine, University of California, San Francisco, CA, USA
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Miaskowski C, Paul SM, Cooper BA, Lee K, Dodd M, West C, Aouizerat BE, Dunn L, Swift PS, Wara W. Predictors of the trajectories of self-reported sleep disturbance in men with prostate cancer during and following radiation therapy. Sleep 2011; 34:171-9. [PMID: 21286498 DOI: 10.1093/sleep/34.2.171] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVES To examine how self-reported ratings of sleep disturbance changed from the time of the simulation visit to four months after the completion of radiation therapy (RT) and to investigate whether specific patient, disease, and symptom characteristics predicted the initial levels of sleep disturbance and/or characteristics of the trajectories of sleep disturbance. DESIGN Prospective longitudinal study. SETTING Two radiation therapy centers. PATIENTS Patients (n = 82) who underwent primary or adjuvant RT for prostate cancer. MEASUREMENTS AND RESULTS Changes in self-reported sleep disturbance were measured using the General Sleep Disturbance Scale (GSDS). Depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression Scale. Trait and state anxiety were measured using the Spielberger State-Trait Anxiety Inventory. Hierarchical linear modeling was used to answer the study aims. Self-reported sleep disturbance increased during the course of RT and then decreased following the completion of RT. Predictors of higher levels of sleep disturbance included younger age, higher levels of trait anxiety, higher levels of depressive symptoms, and higher levels of sleep disturbance at the initiation of RT. CONCLUSIONS Sleep disturbance is a significant problem in patients with prostate cancer who undergo RT. Younger men with co-occurring depression and anxiety may be at greatest risk for sleep disturbance during RT.
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Buffum D, Koetters T, Cho M, Macera L, Paul SM, West C, Aouizerat B, Dunn L, Dodd M, Lee K, Cooper B, Wara W, Swift P, Miaskowski C. The effects of pain, gender, and age on sleep/wake and circadian rhythm parameters in oncology patients at the initiation of radiation therapy. J Pain 2010; 12:390-400. [PMID: 21146465 DOI: 10.1016/j.jpain.2010.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 09/19/2010] [Accepted: 09/29/2010] [Indexed: 11/24/2022]
Abstract
UNLABELLED To date, no studies have evaluated for differences in subjective and objective measures of sleep disturbance in oncology outpatients with and without pain. This descriptive study, recruited 182 patients from 2 radiation therapy (RT) departments at the time of the patient's simulation visit. Approximately 38% of the sample reported moderate to severe pain (ie, worst pain intensity of 6.2 ± 2.4). After controlling for age, patients in pain reported worse sleep quality and more sleep disturbance using the Pittsburgh Sleep Quality Index. With the General Sleep Disturbance Scale, patients in pain reported poorer sleep quality, increased use of sleep medications, and more daytime sleepiness. In addition using an objective measure of sleep disturbance (ie, actigraphy), significant gender × pain interactions were found for sleep onset latency, percentage of time awake at night, wake duration, total sleep time, and sleep efficiency. While no differences were found in female patients, males in pain had worse scores than males without pain. Findings from this study suggest that pain and sleep disturbance are prevalent in oncology outpatients and that a patient's age and gender need to be considered in any evaluation of the relationship between pain and sleep. PERSPECTIVE The effects of pain on subjective and objective sleep parameters appear to be influenced by both patients' age and gender.
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Affiliation(s)
- David Buffum
- School of Nursing, University of California, San Francisco, California, USA
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Merriman JD, Jansen C, Koetters T, West C, Dodd M, Lee K, Paul SM, Aouizerat BE, Cooper BA, Swift PS, Wara W, Miaskowski C. Predictors of the trajectories of self-reported attentional fatigue in women with breast cancer undergoing radiation therapy. Oncol Nurs Forum 2010; 37:423-32. [PMID: 20591802 DOI: 10.1188/10.onf.423-432] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To examine how attentional fatigue changed from the time of simulation to four months after the completion of radiation therapy and to investigate whether specific variables predicted initial levels and trajectories of attentional fatigue. DESIGN Descriptive, longitudinal study. SETTING Two radiation therapy departments. SAMPLE 73 women with breast cancer who received primary or adjuvant radiation therapy. METHODS Participants completed questionnaires prior to, during, and after radiation therapy. Descriptive statistics and hierarchical linear modeling were used for data analysis. MAIN RESEARCH VARIABLES Attentional fatigue; demographic, clinical, and symptom characteristics. FINDINGS Large amounts of interindividual variability were found in the trajectories of attentional fatigue. At baseline, higher levels of attentional fatigue were associated with younger age, not working, a higher number of comorbidities, and higher levels of trait anxiety. The trajectory of attentional fatigue improved over time for women with higher body mass index at baseline. CONCLUSIONS This study is the first to identify predictors of interindividual variability in attentional fatigue in women with breast cancer undergoing radiation therapy. The predictors should be considered in the design of future correlational and interventional studies. IMPLICATIONS FOR NURSING Nurses could use knowledge of the predictors to identify patients at risk for higher levels of attentional fatigue. In addition, nurses could use the information to educate patients about how attentional fatigue may change during and following radiation therapy for breast cancer.
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Affiliation(s)
- John D Merriman
- School of Nursing, University of California, San Francisco, USA
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Miaskowski C, Dodd M, Lee K, West C, Paul SM, Cooper BA, Wara W, Swift PS, Dunn LB, Aouizerat BE. Preliminary evidence of an association between a functional interleukin-6 polymorphism and fatigue and sleep disturbance in oncology patients and their family caregivers. J Pain Symptom Manage 2010; 40:531-44. [PMID: 20570482 PMCID: PMC2952712 DOI: 10.1016/j.jpainsymman.2009.12.006] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 12/19/2009] [Accepted: 01/28/2010] [Indexed: 10/19/2022]
Abstract
CONTEXT Fatigue and sleep disturbance are common problems in oncology patients and their family caregivers (FCs). However, little is known about factors that contribute to interindividual variability in these symptoms or to their underlying biologic mechanisms. OBJECTIVES An evaluation was done on whether genetic variation in a prominent proinflammatory cytokine, interleukin-6 (IL-6 c.-6101A>T [rs4719714]), was associated with mean ratings of evening fatigue, morning fatigue, and sleep disturbance, as well as with the trajectories of these symptoms. METHODS Over six months, participants completed standardized measures of fatigue and sleep disturbance. Linear regression was used to assess the effect of the IL-6 genotype and other covariates on mean fatigue and sleep disturbance scores. Hierarchical linear modeling was used to determine the effect of the IL-6 genotype on symptom trajectories. RESULTS Common allele homozygotes reported higher levels of evening fatigue (P=0.003), morning fatigue (P=0.09), and sleep disturbance (P=0.003) than minor allele carriers. Predictors of baseline level and trajectories of evening fatigue included age, gender, and genotype (intercepts) and baseline level of evening fatigue (slope). Predictors of baseline level and trajectories of morning fatigue included age and genotype (intercept) and age and baseline level of morning fatigue (slope). Predictors of baseline level and trajectories of sleep disturbance included age and genotype (intercept) and baseline level of sleep disturbance (slope). CONCLUSIONS Findings provide preliminary evidence of a genetic association between a functional promoter polymorphism in the IL-6 gene and severity of evening fatigue, morning fatigue, and sleep disturbance in oncology patients and their FCs.
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Affiliation(s)
- Christine Miaskowski
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, CA 94143-0610, USA.
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Dhruva A, Dodd M, Paul SM, Cooper BA, Lee K, West C, Aouizerat BE, Swift PS, Wara W, Miaskowski C. Trajectories of fatigue in patients with breast cancer before, during, and after radiation therapy. Cancer Nurs 2010; 33:201-12. [PMID: 20357659 DOI: 10.1097/ncc.0b013e3181c75f2a] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fatigue is a significant problem associated with radiation therapy (RT). OBJECTIVE This study examined how evening and morning fatigue changed from the time of simulation to 4 months after the completion of RT and investigated whether specific demographic and disease characteristics and baseline severity of symptoms predicted the initial levels of fatigue and characteristics of the trajectories of fatigue. METHODS Seventy-three women with breast cancer completed questionnaires that assessed sleep disturbance, depression, anxiety, and pain prior to the initiation of RT and the Lee Fatigue Scale, over 6 months. Descriptive statistics and hierarchical linear modeling were used for data analysis. RESULTS Large amounts of interindividual variability were found in the trajectories of fatigue. Evening fatigue at baseline was negatively influenced by having children at home and depression. The trajectory of evening fatigue was worse for women who were employed. Morning fatigue at baseline was influenced by younger age, lower body mass index, and the degree of sleep disturbance and trait anxiety. Trajectories of morning fatigue were worse for patients with a higher disease stage and more medical comorbidities. CONCLUSION Interindividual and diurnal variability in fatigue found in women with breast cancer is similar to that found in men with prostate cancer. However, the predictors of interindividual variability in fatigue between these 2 cohorts were different. IMPLICATIONS FOR PRACTICE Diurnal variability and different predictors for morning and evening fatigue suggest different underlying mechanisms. The various predictors of fatigue need to be considered in the design of future intervention studies.
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Affiliation(s)
- Anand Dhruva
- Schools of Medicine, University of California, San Francisco, California 94143-0610, USA
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Howlett K, Koetters T, Edrington J, West C, Paul S, Lee K, Aouizerat BE, Wara W, Swift P, Miaskowski C. Changes in sexual function on mood and quality of life in patients undergoing radiation therapy for prostate cancer. Oncol Nurs Forum 2010; 37:E58-66. [PMID: 20044333 DOI: 10.1188/10.onf.e58-e66] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To describe the percentages of men with and without changes in sexual function from the beginning to end of radiation therapy and evaluate for differences in demographic and clinical characteristics, mood states, and quality of life (QOL) among patients who did and did not experience changes in sexual function. DESIGN Descriptive, longitudinal. SETTING Two radiation therapy departments in northern California. SAMPLE 70 men with prostate cancer who underwent primary or adjuvant radiation therapy. METHODS Self-report questionnaires, medical record reviews, and repeated measures analysis of variance. MAIN RESEARCH VARIABLES Changes in sexual function; depression, anxiety, and QOL. FINDINGS Patients were categorized into one of four sex groups (No Problem X 2, Problem-No Problem, No Problem-Problem, and Problem X 2) based on their responses to "Is your sexuality impacted by your illness?" at the beginning and end of radiation therapy. About 50% had a problem with sexual function either at the beginning or end of radiation therapy. Overall, men without sexual problems at both the beginning and end of radiation therapy had significantly less anxiety and depression and higher QOL scores than patients who developed a problem at the end and patients who had a problem at both time points. CONCLUSIONS Changes in sexual function during the course of radiation therapy affect patients' mood and QOL. IMPLICATIONS FOR NURSING Clinicians should evaluate the effects of radiation therapy on sexual function and monitor patients with prostate cancer for depression and anxiety as well as for changes in QOL.
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Van Onselen C, Dunn LB, Lee K, Dodd M, Koetters T, West C, Paul SM, Aouizerat BE, Wara W, Swift P, Miaskowski C. Relationship between mood disturbance and sleep quality in oncology outpatients at the initiation of radiation therapy. Eur J Oncol Nurs 2010; 14:373-9. [PMID: 20080444 DOI: 10.1016/j.ejon.2009.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2009] [Revised: 11/29/2009] [Accepted: 12/02/2009] [Indexed: 12/01/2022]
Abstract
PURPOSE OF THE RESEARCH The purpose of this study was to describe the occurrence of significant mood disturbance and evaluate for differences in sleep quality among four mood groups (i.e., neither anxiety nor depression, only anxiety, only depression, anxiety and depression) prior to the initiation of radiation therapy (RT). METHODS AND SAMPLE Patients (n=179) with breast, prostate, lung, and brain cancer were evaluated prior to the initiation of RT using the Pittsburgh Sleep Quality Index (PSQI), the Center for Epidemiological Studies Depression Scale, and the Spielberger State Anxiety Inventory. Differences in sleep disturbance among the four mood groups were evaluated using analyses of variance. KEY RESULTS While 38% of the patients reported some type of mood disturbance, 57% of the patients reported sleep disturbance. Patients with clinically significant levels of anxiety and depression reported the highest levels of sleep disturbance. CONCLUSIONS Overall, oncology patients with mood disturbances reported more sleep disturbance than those without mood disturbance. Findings suggest that oncology patients need to be assessed for mood and sleep disturbances.
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Willette-Murphy K, Lee KA, Dodd M, West C, Aouizerat BE, Paul S, Swift P, Wara W, Miaskowski C. Relationship between sleep and physical activity in female family caregivers at the initiation of patients' radiation therapy. J Obstet Gynecol Neonatal Nurs 2009; 38:367-74. [PMID: 19538626 DOI: 10.1111/j.1552-6909.2009.01032.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To evaluate for differences in subjective and objective measures of sleep between physically active and inactive female family caregivers of oncology patients at the initiation of their spouses' radiation therapy and evaluate for differences in demographic, clinical, and symptom characteristics between women in the 2 activity groups. DESIGN Descriptive, cross-sectional study. SETTING Two radiation treatment centers. PARTICIPANTS Female family caregivers of patients who began radiation therapy for prostate, lung, or brain cancer. METHODS Women were categorized as inactive (n=38) or active (n=30) based on self-report ratings of activity over a period of 2 days. Activity groups were compared on demographic and clinical characteristics, self-reported measures of sleep and other symptoms, and objective measures of sleep using wrist actigraphy. RESULTS Inactive women had a higher number of comorbid conditions, lower levels of attentional function, less self-reported sleep time, a longer sleep onset latency, and a higher percentage of daytime sleep as measured by actigraphy compared with active women. CONCLUSIONS Inactivity in female family caregivers of oncology patients is associated with poorer self-reported sleep and decreased attentional function.
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Aouizerat BE, Dodd M, Lee K, West C, Paul SM, Cooper BA, Wara W, Swift P, Dunn LB, Miaskowski C. Preliminary evidence of a genetic association between tumor necrosis factor alpha and the severity of sleep disturbance and morning fatigue. Biol Res Nurs 2009; 11:27-41. [PMID: 19419979 DOI: 10.1177/1099800409333871] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Although fatigue and sleep disturbance are prevalent symptoms in oncology patients and their family caregivers, little is known about the factors that contribute to interindividual variability in symptom severity ratings as well as in their underlying biological mechanisms. In this study, we sought to determine whether a functional genetic variation in a prominent proinflammatory cytokine, tumor necrosis factor-alpha (TNFA-308G>A [rs1800629] promoter polymorphism) was associated with overall ratings of sleep disturbance and fatigue as well as with the trajectories of these symptoms. Over 6 months, participants completed standardized measures of sleep disturbance and fatigue. Multiple linear regression was used to assess the effect of the TNFA genotype and other covariates on mean sleep disturbance and fatigue scores. Hierarchical linear modeling was used to determine the effect of TNFA genotype on the trajectories of these symptoms. Common allele homozygotes reported higher levels of sleep disturbance (p=.09) and morning fatigue (p=.02) than minor allele carriers. Multivariate analyses demonstrated that age and genotype were predictors of both mean symptom scores and the trajectories of these symptoms. Findings provide preliminary evidence of an association between a functional promoter polymorphism in the TNFA gene and the severity of sleep disturbance and morning fatigue in oncology patients and their family caregivers.
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Affiliation(s)
- Bradley E Aouizerat
- School of Nursing, Institute for Human Genetics, University of California, San Francisco, California 94143-0610, USA
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Fletcher BAS, Schumacher KL, Dodd M, Paul SM, Cooper BA, Lee K, West C, Aouizerat BE, Swift PS, Wara W, Miaskowski C. Trajectories of fatigue in family caregivers of patients undergoing radiation therapy for prostate cancer. Res Nurs Health 2009; 32:125-39. [PMID: 19072846 DOI: 10.1002/nur.20312] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Predictors of and trajectories for evening and morning fatigue were evaluated in family caregivers of oncology patients using hierarchical linear modeling. Evening fatigue trajectory fit a quadratic model. Predictors included baseline sleep disturbances in family caregivers and baseline evening fatigue in patients. Morning fatigue trajectory fit a linear model. Predictors were baseline trait anxiety, levels of perceived family support, and baseline morning fatigue in patients. Findings suggest considerable inter-individual variability in the trajectories of evening and morning fatigue. Evaluating family caregivers for sleep disturbance, anxiety, and poor family support, as well as high levels of patient fatigue, could identify those family caregivers at highest risk for sustained fatigue trajectories.
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Kim E, Jahan T, Aouizerat BE, Dodd MJ, Cooper BA, Paul SM, West C, Lee K, Swift PS, Wara W, Miaskowski C. Changes in symptom clusters in patients undergoing radiation therapy. Support Care Cancer 2009; 17:1383-91. [PMID: 19242732 PMCID: PMC2762051 DOI: 10.1007/s00520-009-0595-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Accepted: 02/02/2009] [Indexed: 11/29/2022]
Abstract
GOALS OF WORK The goals of the study were to determine the occurrence rates for and the severity of symptoms at the middle, end, and 1 month after the completion of radiation therapy (RT), to determine the number and types of symptom clusters at these three time points, and to evaluate for changes over time in these symptom clusters. MATERIALS AND METHODS Symptom occurrence and severity were evaluated using the Memorial Symptom Assessment Scale (MSAS) in a sample of patients (n = 160) who underwent RT for breast or prostate cancer. At each time point, an exploratory factor analysis was done to determine the number of symptom clusters (i.e., symptom factors) based on the MSAS symptom severity ratings. MAIN RESULTS The majority of the patients were male and married with a mean age of 61.1 years. The five symptoms with the highest occurrence rates across all three time points were lack of energy, pain, difficulty sleeping, feeling drowsy, and sweats. Although the number of symptoms and the specific symptoms within each symptom cluster were not identical across the three time points, three relatively similar symptom clusters (i.e., "mood-cognitive" symptom cluster, "sickness-behavior" symptom cluster, "treatment-related", or "pain" symptom cluster) were identified in this sample. The internal consistency coefficients for the mood-cognitive symptom cluster and sickness-behavior symptom cluster were adequate at > or =0.68. CONCLUSIONS Three relatively stable symptom clusters were found across RT. The majority of the symptom cluster severity scores were significantly higher in patients with breast cancer compared to patients with prostate cancer.
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Affiliation(s)
- Esther Kim
- School of Nursing, University of California, San Francisco, CA, USA
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Miaskowski C, Paul SM, Cooper BA, Lee K, Dodd M, West C, Aouizerat BE, Swift PS, Wara W. Trajectories of fatigue in men with prostate cancer before, during, and after radiation therapy. J Pain Symptom Manage 2008; 35:632-43. [PMID: 18358683 PMCID: PMC2491660 DOI: 10.1016/j.jpainsymman.2007.07.007] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Revised: 07/02/2007] [Accepted: 07/30/2007] [Indexed: 11/21/2022]
Abstract
Fatigue is the most common and distressing symptom reported by patients undergoing radiation therapy (RT). However, limited information is available on the trajectories of fatigue, as well as on the predictors of interindividual variability in fatigue. This study evaluated a sample of patients who underwent RT for prostate cancer to examine how ratings of evening and morning fatigue changed from the time of simulation to four months after the completion of RT and to investigate whether specific patient, disease, and symptom characteristics predicted the initial levels of fatigue and/or characteristics of the trajectories of evening and morning fatigue. Using hierarchical linear modeling, a large amount of interindividual variability was demonstrated in the trajectories of evening and morning fatigue. Findings from this study suggest that younger men with a higher level of fatigue at the time of the simulation visit were at increased risk for higher levels of evening and morning fatigue over the course of RT. In addition, the level of morning fatigue over the course of RT appears to depend on the patient's level of depression at the time of the simulation visit. In future studies, the use of hierarchical linear modeling as an analytic tool will assist in the identification of patients who are most at risk for prolonged fatigue trajectories. This type of analysis may lead to the identification of subgroups of patients who are at higher risk for negative outcomes and who require different types of interventions for the fatigue associated with RT.
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Affiliation(s)
- Christine Miaskowski
- Department of Physiological Nursing, University of California, San Francisco, CA 94143-0610, USA.
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20
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Mishra KK, Banerjee A, Squire S, Lamborn K, Wara W, Prados MD, Haas-Kogan DA. 15-year results for upfront TPDCV chemotherapy phase II trial for pediatric low-grade hypothalamic/chiasmatic gliomas. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.10041] [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: 11/20/2022] Open
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Fletcher BS, Paul SM, Dodd MJ, Schumacher K, West C, Cooper B, Lee K, Aouizerat B, Swift P, Wara W, Miaskowski CA. Prevalence, severity, and impact of symptoms on female family caregivers of patients at the initiation of radiation therapy for prostate cancer. J Clin Oncol 2008; 26:599-605. [PMID: 18235118 DOI: 10.1200/jco.2007.12.2838] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE In a sample of family caregivers (FCs) of patients with prostate cancer who were to begin radiation therapy (RT), the purposes were to determine the prevalence and severity of depression, anxiety, pain, sleep disturbance, and fatigue; determine the relationships among these symptoms and between these symptoms and functional status and quality of life (QOL); evaluate for differences in functional status and QOL between FCs with low and high levels of these symptoms; and determine which factors predicted FCs' functional status and QOL. PATIENTS AND METHODS FCs were recruited before patients initiated RT and completed self-report questionnaires that evaluated demographic characteristics, symptoms, functional status, and QOL. RESULTS Sixty female FCs participated in the study. On the basis of established cut point scores for each symptom questionnaire, 12.2% of the FCs had clinically meaningful levels of depression, 40.7% anxiety, 15.0% pain, 36.7% sleep disturbance, 33.3% morning fatigue, and 30.0% evening fatigue. FCs who were older and who had lower levels of state anxiety and higher levels of depression, morning fatigue, and pain reported significantly poorer functional status (R(2) = 38.7%). FCs who were younger, had more years of education, were working, and who had higher levels of depression, morning fatigue, sleep disturbance, and lower levels of evening fatigue reported significantly lower QOL scores (R(2) = 70.1%). CONCLUSION A high percentage of FCs experienced clinically meaningful levels of a variety of symptoms. These symptoms have a negative impact on the FCs' functional status and QOL.
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Chang SM, Lamborn KR, Malec M, Larson D, Wara W, Sneed P, Rabbitt J, Page M, Nicholas MK, Prados MD. Phase II study of temozolomide and thalidomide with radiation therapy for newly diagnosed glioblastoma multiforme. Int J Radiat Oncol Biol Phys 2004; 60:353-7. [PMID: 15380566 DOI: 10.1016/j.ijrobp.2004.04.023] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.6] [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: 12/29/2003] [Revised: 03/15/2004] [Accepted: 04/02/2004] [Indexed: 11/28/2022]
Abstract
PURPOSE The chemotherapeutic agent temozolomide (TMZ) and the antiangiogenic agent thalidomide have both demonstrated antitumor activity in patients with recurrent malignant glioma. The objectives of this study were to determine if the combined strategy of these oral agents with radiation therapy (RT) is associated with an improved median survival of patients with newly diagnosed glioblastoma multiforme and to evaluate toxicity. METHODS AND MATERIALS Sixty-seven patients were enrolled in this trial. Radiotherapy parameters were a total dose of 60 Gy delivered in 2 Gy fractions over 6 weeks. Temozolomide was administered starting the first day of RT at 150 mg/m(2) daily for 5 days every 4 weeks for the first cycle and escalated to a maximum dose of 200 mg/m(2). Thalidomide was started on Day 7 of RT at 200 mg and escalated by 100-200 mg every 1-2 weeks depending on patient tolerance, to a maximum of 1,200 mg daily. RESULTS Sixty-one patients have progressed, with a median time to progression of 22 weeks. Fifty-six patients have died, and the median survival was 73 weeks. CONCLUSIONS This strategy of combination TMZ, thalid and RT was relatively well tolerated with favorable survival outcome for patients with GM when compared to patients not treated with adjuvant chemotherapy and similar to those who have received nitrosourea adjuvant chemotherapy. It is unclear the added advantage thalid has in combination with TMZ for this patient population.
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Affiliation(s)
- Susan M Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
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Ojemann SG, Sneed PK, Larson DA, Gutin PH, Berger MS, Verhey L, Smith V, Petti P, Wara W, Park E, McDermott MW. Radiosurgery for malignant meningioma: results in 22 patients. J Neurosurg 2000. [DOI: 10.3171/jns.2000.93.supplement_3.0062] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The initial treatment of malignant meningiomas in the past has included surgical removal followed by fractionated external-beam radiotherapy. Radiosurgery has been added to the options for treatment of primary or recurrent tumors over the last 10 years. The authors report their results of using gamma knife radiosurgery (GKS) to treat 22 patients over an 8-year period.
Methods. Twenty-two patients who underwent GKS for malignant meningioma between December 1991 and May 1999 were evaluated. Three patients were treated with GKS as a boost to radiotherapy and 19 for recurrence following radiotherapy. Outcome factors including patient survival, freedom from progression, and complications were analyzed. In addition, in the recurrent group, variables such as patient age, sex, tumor location, target volume, margin dose, and maximum dose were also analyzed. Univariate and multivariate analyses were performed.
Overall 5-year survival and progression-free survival estimates were 40% and 26%, respectively. Age (p ≤ 0.003) and tumor volume (p ≤ 0.05) were significant predictors of time to progression and survival in both univariate and multivariate analyses. Five patients (23%) developed radiation necrosis. Significant relationships between complications and treatment variables or patient characteristics could not be established.
Conclusions. Tumor control following GKS is greater in patients with smaller-sized tumors (< 8 cm3) and in younger patients. Gamma knife radiosurgery can be performed to treat malignant meningioma with acceptable toxicity. The efficacy of GKS relative to other therapies for recurrent malignant meningioma as well as the value of GKS as a boost to radiotherapy will require further evaluation.
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Moore IM, Espy KA, Kaufmann P, Kramer J, Kaemingk K, Miketova P, Mollova N, Kaspar M, Pasvogel A, Schram K, Wara W, Hutter J, Matthay K. Cognitive consequences and central nervous system injury following treatment for childhood leukemia. Semin Oncol Nurs 2000; 16:279-90; discussion 291-9. [PMID: 11109272 DOI: 10.1053/sonu.2000.16582] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine the relationship between membrane damage and intellectual and academic abilities in children with acute lymphoblastic leukemia (ALL) and pilot test a math intervention for children with ALL who were affected. DATA SOURCES Research studies and review articles. CONCLUSIONS Despite the prophylactic central nervous system (CNS) treatment for long-term disease-free survival, many children with ALL subsequently experience declines in intellectual and academic skills. IMPLICATIONS FOR NURSING PRACTICE Improving academic abilities in children who have received CNS treatment is of high priority and may have longlasting implications on quality of life.
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Affiliation(s)
- I M Moore
- Division of Nursing Practice, College of Nursing, University of Arizona, Tucson 85721-0203, USA
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Levin VA, Lamborn K, Wara W, Davis R, Edwards M, Rabbitt J, Malec M, Prados MD. Phase II study of 6-thioguanine, procarbazine, dibromodulcitol, lomustine, and vincristine chemotherapy with radiotherapy for treating malignant glioma in children. Neuro Oncol 2000; 2:22-8. [PMID: 11302250 PMCID: PMC1920700 DOI: 10.1093/neuonc/2.1.22] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We conducted a single-arm phase II study to evaluate the efficacy and safety of radiotherapy combined with 6-thioguanine, procarbazine, dibromodulcitol, lomustine, and vincristine (TPDCV) chemotherapy for treating malignant astrocytoma in children and anaplastic ependymoma in patients of all ages. Between 1984 and 1992, 42 patients who had malignant astrocytomas (glioblastomas multiforme, anaplastic astrocytomas, or mixed anaplastic oligoastrocytomas) were treated with TPDCV chemotherapy and radiation therapy. Of these patients, 40 were younger than 18 years, but 2 were older (22 and 23 years) when treated. Cranial radiation averaged 58 Gy. TPDCV chemotherapy was given for 1 year or until progression. Between 1989 and 1991, 17 patients with malignant ependymoma were treated with TPDCV chemotherapy and craniospinal radiation. Radiation was given at an average dose of 54 Gy to the tumor, 28 Gy to the whole brain, and 31 Gy to the spinal axis. TPDCV chemotherapy was given for 1 year or until tumor progressed. Of the patients with glioblastoma multiforme, 13 of 17 died; the median time to progression was 49 weeks, and median survival was 85 weeks. The four patients surviving at this writing were followed a median 537 weeks (range 364-635 weeks). Of the patients with nonglioblastoma malignant astrocytoma, 14 of 25 died; the median time to progression was 224 weeks. Median survival was not reached in this group. The median follow-up for those surviving was 494 weeks. For the patients with ependymoma, 11 of 17 died with a median time to progression of 141 weeks. The median follow-up for the eight who survive was 469 weeks. Nine patients died with a median survival of 183 weeks. The combination of TPDCV and radiotherapy has activity against childhood anaplastic astrocytoma, glioblastoma multiforme, and anaplastic ependymoma. The results of this study for children with glioblastoma were comparable to results in the literature, while the results for children with anaplastic astrocytoma appeared better than most reports. The combination of TPDCV chemotherapy and radiation therapy for anaplastic ependymomas appears to be active and at least as good as published reports using radiation therapy alone.
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Affiliation(s)
- V A Levin
- Brain Tumor Center and the Department of Neuro-Oncology, Houston, TX 77030, USA
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Bauman G, Lote K, Larson D, Stalpers L, Leighton C, Fisher B, Wara W, MacDonald D, Stitt L, Cairncross JG. Pretreatment factors predict overall survival for patients with low-grade glioma: a recursive partitioning analysis. Int J Radiat Oncol Biol Phys 1999; 45:923-9. [PMID: 10571199 DOI: 10.1016/s0360-3016(99)00284-9] [Citation(s) in RCA: 180] [Impact Index Per Article: 7.2] [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: 11/21/2022]
Abstract
PURPOSE Three databases were pooled and analyzed to determine which groupings of prognostic factors best predicted overall survival for patients with low-grade gliomas treated with surgery and immediate or delayed radiotherapy. METHODS AND MATERIALS Databases of patients with low-grade gliomas compiled at the London Regional Cancer Centre (LRCC), the Norwegian Radium Hospital (NRH), and the University of California, San Francisco (UCSF) were merged. Inclusion criteria for the pooled analysis included: age > or =18 years and histologically confirmed low-grade (World Health Organization Grade II) supratentorial fibrillary astrocytoma, oligodendroglioma or mixed oligoastrocytoma. Factors analyzed for prognostic significance included: age at diagnosis, gender, seizures at presentation, presence of enhancement on computed tomography (CT) or magnetic resonance imaging (MRI), Karnofsky Performance Status (KPS) at diagnosis, histology, extent of surgical resection, timing of radiotherapy, and treating institution. Univariate and multivariate analysis of overall survival for these factors was performed. Recursive partitioning was performed to generate prognostic groups using these factors. RESULTS From the combined databases, 401 patients were eligible for analysis. Median survival for the entire group was 95 months/7.9 years. On univariate analysis age 18-40, presence of seizures at presentation, KPS > or =70, treating institution, and absence of contrast enhancement were associated with improved overall survival. On multivariate analysis, these factors remained independent predictors of improved overall survival. Recursive partitioning analysis yielded four prognostic groups with statistically different median survivals (MS): Group I (n = 41: KPS <70, age >40) MS 12 months; Group II (n = 34: KPS > or =70, age >40, enhancement present) MS 46 months; Group III (n = 138: KPS <70, age 18-40 or KPS > or =70 age >40, no enhancement) MS 87 months; Group IV (n = 188: KPS > or =70, age 18-40) MS 128 months. CONCLUSION Clusters of pretreatment prognostic factors described subgroups of low-grade glioma patients with divergent overall survivals. Consideration of these prognostic subgroups may be important when considering timing of interventions for these patients and in the stratification of patients for clinical trials.
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Affiliation(s)
- G Bauman
- Department of Oncology, University of Western Ontario, and London Regional Cancer Centre, Canada.
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Miyawaki L, Dowd C, Wara W, Goldsmith B, Albright N, Gutin P, Halbach V, Hieshima G, Higashida R, Lulu B, Pitts L, Schell M, Smith V, Weaver K, Wilson C, Larson D. Five year results of LINAC radiosurgery for arteriovenous malformations: outcome for large AVMS. Int J Radiat Oncol Biol Phys 1999; 44:1089-106. [PMID: 10421543 DOI: 10.1016/s0360-3016(99)00102-9] [Citation(s) in RCA: 176] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE For radiosurgery of large arteriovenous malformations (AVMs), the optimal relationship of dose and volume to obliteration, complications, and hemorrhage is not well defined. Multivariate analysis was performed to assess the relationship of multiple AVM and treatment factors to the outcome of AVMs significantly larger than previously reported in the literature. METHODS AND MATERIALS 73 patients with intracranial AVMs underwent LINAC radiosurgery. Over 50% of the AVMs were larger than 3 cm in diameter and the median and mean treatment volumes were 8.4 cc and 15.3 cc, respectively (range 0.4-143.4 cc). Minimum AVM treatment doses varied between 1000-2200 cGy (median: 1600 cGy). RESULTS The obliteration rates for treatment volumes < 4 cc, 4-13.9 cc, and > or = 14 cc were 67%, 58%, and 23%, respectively. AVM obliteration was significantly associated with higher minimum treatment dose and negatively associated with a history of prior embolization with particulate materials. No AVM receiving < 1400 cGy was obliterated. The incidence of post-radiosurgical imaging abnormalities and clinical complications rose with increasing treatment volume. For treatment volumes > 14 cc receiving > or = 1600 cGy, the incidence of post-radiosurgical MRI T2 abnormalities was 72% and the incidence of radiation necrosis requiring resection was 22%. The rate of post-radiosurgical hemorrhage was 2.7% per person-year for AVMs with treatment volumes < 14 cc and 7.5% per person-year for AVMs > or = 14 cc. CONCLUSION As AVM size increases, the dose-volume range for the optimal balance between successful obliteration and the risk of complications and post-radiosurgical hemorrhage narrows.
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Affiliation(s)
- L Miyawaki
- Department of Radiation Oncology, University of California at San Francisco, USA
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Bauman G, Lote K, Larson D, Statpers L, Leighton C, Fisher B, Wara W, Macdonald D, Stitt L, Cairncross J. 127 Pre-treatment factors predict overall survival for patients with low grade glioma: A recursive partitioning analysis. Int J Radiat Oncol Biol Phys 1999. [DOI: 10.1016/s0360-3016(99)90145-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Sweeney PJ, Nicolae D, Ignacio L, Chen L, Roach M, Wara W, Marcus KC, Vijayakumar S. Effect of subcutaneous recombinant human erythropoietin in cancer patients receiving radiotherapy: final report of a randomized, open-labelled, phase II trial. Br J Cancer 1998; 77:1996-2002. [PMID: 9667681 PMCID: PMC2150364 DOI: 10.1038/bjc.1998.331] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The purpose of this study was to determine the safety, efficacy and impact on quality of life of recombinant human erythropoietin (r-HuEPO) for cancer patients undergoing radiotherapy (RT). An open-labelled randomized design was used, with patients randomized to either treatment or control arms. Patients in the treatment arm received r-HuEPO given by subcutaneous injection at a dose of 200 units kg(-1) day(-1) plus oral iron supplements (ferrous sulphate 325 mg p.o. t.i.d.). Entry was restricted to patients with carcinoma of the lung, uterine cervix, prostate or breast who presented for RT with anaemia parameters reflective of 'the anaemia of chronic disease'. Radiotherapy policies (portals, doses, fraction size, etc.) were determined by the site and stage of disease. Complete blood counts (CBCs) were obtained weekly. The target level of haemoglobin was 15 g dl(-1) for men and 14 g dl(-1) for women. Quality of life (QOL) was assessed weekly by using an analogue scale to judge energy, activities of daily living and overall quality of life. Forty-eight patients were entered in the study, 24 in the treatment arm and 24 in the control arm. The prerandomization demographic characteristics and mean laboratory values were comparable in both arms. The mean haemoglobin at completion was 13.6 g dl(-1) for r-HuEPO-treated patients compared with 11.0 g dl(-1) for control subjects (P = 0.0012). Patients who received r-HuEPO demonstrated a mean weekly haemoglobin increase of 0.41 g dl(-1) compared with a decrease in mean haemoglobin level in controls for 6 of the 7 weeks of the study (mean weekly decrease of 0.073 g dl(-1)). Target levels of haemoglobin were achieved by 41.6% of r-HuEPO-treated patients compared with none of the control subjects. The mean platelet count declined in both arms of the study with RT but the decline from pretreatment was less rapid in r-HuEPO-treated patients (11.2% decrease) compared with controls (26.3% decrease) and was statistically significant during weeks 4-6. Toxicity was minor with only mild irritation at the injection site. Mean quality of life end points were superior in the treatment arm but not statistically significant. r-HuEPO had a beneficial effect on weekly haemoglobin levels in patients undergoing RT with response rates similar to other studies. There was also a less rapid decline in weekly platelet counts in r-HuEPO-treated patients compared with control subjects. Further studies are needed to address the optimum dose and scheduling as well as the impact of r-HuEPO on clinical outcomes.
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Affiliation(s)
- P J Sweeney
- Department of Radiation and Cellular Oncology, University of Chicago, IL, USA
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30
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Miyawaki L, Dowd C, Wara W, Smith V, Albright N, Weaver K, Ling C, Lulu B, Schell M, Larson D. 128 Five year results for linac radiosurgery for arteriovenous malformations: Poor outcome for large AVMs. Int J Radiat Oncol Biol Phys 1997. [DOI: 10.1016/s0360-3016(97)80686-4] [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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31
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Prados MD, Wara W, Edwards MS, Ater J, Rabbit J, Lamborn K, Davis R, Levin VA. Treatment of high-risk medulloblastoma and other primitive neuroectodermal tumors with reduced dose craniospinal radiation therapy and multi-agent nitrosourea-based chemotherapy. Pediatr Neurosurg 1996; 25:174-81. [PMID: 9293544 DOI: 10.1159/000121120] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To investigate toxicity, and progression-free survival (PFS) of children and adults with newly diagnosed medulloblastoma, pineoblastoma, and other primitive neuroectodermal tumors (PNET) with a combined modality regimen of radiation therapy and adjuvant nitrosourea-based chemotherapy. PATIENTS AND METHODS Between 1984 and 1992, 34 evaluable patients with newly diagnosed tumors were treated with chemotherapy and radiotherapy according to a single-arm phase II study. One cycle of chemotherapy was given prior to and for 6 cycles following craniospinal radiotherapy (CSA). Procarbazine, 6-thioguanine, and dibromodulcitol were given before lomustine (CCNU) to enhance CCNU-induced tumor cell kill and to reduce alkyltransferase repair of ethylated DNA. Vincristine was given 1 and 3 weeks after CCNU to kill cells that began to cycle after the challenge of the first four drugs. Chemotherapy was given in the outpatient setting. CSA radiation was planned to deliver a dose of 54 Gy to the primary tumor site and 24 Gy to the rest of the neuroaxis. Additional radiation was given to bulky disease outside the primary site if present. Hydroxyurea was used during radiotherapy as a radiosensitizer. RESULTS Patients treated included 27 with medulloblastoma, 5 with pineoblastoma, and 2 with supratentorial PNET. All but 3 medulloblastoma cases were considered high risk either because of bulky residual disease remaining after surgery and/or metastatic disease detected during staging. For the 34 patients, 24 have progressed, 20 have died. Overall estimated PFS was 55% at 3 years and 35% at 5 years. The 5-year survival estimate is 56%. One patient had inadequate staging to determine M stage. Of the remaining 33 patients, there were 19 patients who had metastatic disease at diagnosis (M1 or higher stage) who had a 3- and 5-year PFS of 42 and 21% respectively and 5-year survival of 42%. There were 14 patients who had negative staging (M0 stage) who had a 3- and 5-year PFS of 69 and 52% respectively and 5-year survival of 71%. Of the 27 patients with medulloblastoma, 15 had M1 or higher stage. These 15 patients had a 5-year PFS and overall survival of only 20 and 40% respectively. Medulloblastoma patients with M0 staging had a 5-year PFS and overall survival of 52 and 73% respectively. Overall toxicity was primarily due to mild hematological toxicity and related to the use of the chemotherapy. CONCLUSIONS The results using this therapy in high-risk groups of patients does not offer any improvement over results reported in other recent studies. The reason for these results may be due to the lowered craniospinal radiation dose.
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Affiliation(s)
- M D Prados
- Department of Neurosurgery, University of California, San Francisco, USA.
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Packer RJ, Prados M, Phillips P, Nicholson HS, Boyett JM, Goldwein J, Rorke LB, Needle MN, Sutton L, Zimmerman RA, Fitz CR, Vezina LG, Etcubanas E, Wallenberg JC, Reaman G, Wara W. Treatment of children with newly diagnosed brain stem gliomas with intravenous recombinant beta-interferon and hyperfractionated radiation therapy: a childrens cancer group phase I/II study. Cancer 1996; 77:2150-6. [PMID: 8640684 DOI: 10.1002/(sici)1097-0142(19960515)77:10<2150::aid-cncr28>3.0.co;2-t] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prognosis for the majority of children with brain stem gliomas is dismal. In previous studies, recombinant beta-interferon (r beta IF) has been shown to be effective for children with recurrent brain stem gliomas and may also act synergistically with radiotherapy (RT). METHODS Thirty-two children with diffuse intrinsic brain stem gliomas were treated with (r beta IF) and 7200 centigray (cGy) of hyperfractionated RT (100 cGy twice-daily fractions) to determine the toxicity of treatment and the tolerance of the brain stem to this regimen, as well as to assess survival. Patients were treated with r beta IF 3 times per week during RT and then for 8 weeks following RT. Initially, a dose escalation trial was performed. RESULTS Interferon was initially begun at 12.5 x 10(6) IU/m2 and escalated up to 400 x 10(6) IU/m2. The safe starting dose was determined to be 100 x 10 (6) IU/m2. Due to unacceptable toxicity, the maintenance dose was reduced to 200 x 10 (6) IU/m2. Therapy was relatively well tolerated, although 13 of the patients required dose modifications due to hepatic or hematologic toxicity. Four of the patients had to discontinue treatment due to this toxicity. One patient died while receiving maintenance IF of encephalopathy, seizures, and brain stem dysfunction; believed possibly due to the r beta IF. Thirty of the 32 patients have developed progressive disease. The median time to progression from study entry was five months and the median time to death was 9 months. CONCLUSIONS We conclude that r beta IF plus hyperfractionated therapy can be tolerated by children with newly diagnosed brain stem gliomas, although there is occasional dose-limiting hepatic, blood, and central nervous system toxicity. This therapy did not result in a higher rate of disease control.
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Affiliation(s)
- R J Packer
- Department of Neurology, Children's National Medical Center, George Washington University, Washington, D.C., USA
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Fischbein NJ, Prados MD, Wara W, Russo C, Edwards MS, Barkovich AJ. Radiologic classification of brain stem tumors: correlation of magnetic resonance imaging appearance with clinical outcome. Pediatr Neurosurg 1996; 24:9-23. [PMID: 8817611 DOI: 10.1159/000121010] [Citation(s) in RCA: 129] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Although tumors of the brain stem have traditionally been classified as a single entity, these tumors are increasingly being recognized as a heterogeneous group, with some subgroups having better prognoses for long-term survival. Although several systems for classification of brain stem tumors have been proposed, none have been based on data derived from contrast-enhanced magnetic resonance (MR) imaging. In this review, we present a classification scheme based on our review of the literature and of the MR scans of 64 patients with brain stem tumors. In addition, we assess the contribution of gadolinium to the classification of brain stem tumors and correlate the various tumor subtypes, based on MR appearance, with prognosis. Our results suggest that the most important factor in determining prognosis based on MR characteristics is whether the tumor is diffuse or focal. Focal tumors have an excellent prognosis regardless of the site of tumor origin. Diffuse tumors of the mesencephalon and pons have a significantly poorer prognosis than focal tumors (p = 0.0013), with diffuse pontine tumors having the worst prognosis. Differentiation of diffuse and focal medullary tumors was difficult, possibly explaining the lack of significant difference in the survival of patients with diffuse versus focal medullary tumors. The presence or absence of enhancement after the administration of paramagnetic contrast has no significant relation with outcome, overall or within specific tumor subgroups.
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Affiliation(s)
- N J Fischbein
- Department of Radiology, University of California at San Francisco 94143-0628, USA
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Wara W, Bauman G, Gutin P, Circillo S, Larson D, McDermott M, Sneed P, Verhey L, Smith V, Petti P. Stereotactic radiosurgery in children. Stereotact Funct Neurosurg 1995; 64 Suppl 1:118-25. [PMID: 8584819 DOI: 10.1159/000098771] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [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: 01/31/2023]
Abstract
The role of stereotactic radiosurgery in the treatment of pediatric patients is still being explored. We report the Gamma Knife treatment of 33 patients under the age of 21, at the University of California, San Francisco, between the years 1991 and 1993. Treatment-related toxicity has been low. 10/14 patients treated for arteriovenous malformation (AVM) with follow-up > 1 month have shown partial or complete AVM obliteration. No patient has had a new hemorrhage after AVM treatment. In children with malignant tumors, treatment was well tolerated, although most patients, ultimately, had progressive disease. Stereotactic radiosurgery is logistically possible in the pediatric population. Its use in selected patients with AVMs seems appropriate, although its role in the treatment of malignant brain tumors remains to be defined.
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Affiliation(s)
- W Wara
- University of California, San Francisco, USA
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35
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Vijayakumar S, Roach M, Wara W, Chan SK, Ewing C, Rubin S, Sutton H, Halpern H, Awan A, Houghton A. Effect of subcutaneous recombinant human erythropoietin in cancer patients receiving radiotherapy: preliminary results of a randomized, open-labeled, phase II trial. Int J Radiat Oncol Biol Phys 1993; 26:721-9. [PMID: 8331011 DOI: 10.1016/0360-3016(93)90299-b] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.5] [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: 01/29/2023]
Abstract
PURPOSE To determine the efficacy and safety of subcutaneous administration of recombinant human erythropoietin (r-HuEPO) at a dose of 200 units/kg/day to cancer patients undergoing radiotherapy. METHODS AND MATERIALS This is a randomized, open-labeled, Phase II study. Only patients receiving radiotherapy +/- chemotherapy are included. Eligibility is restricted to patients with lung cancer, carcinoma of the uterine cervix, prostatic adenocarcinoma, or adenocarcinoma of the breast. Patients in the control and treatment arms receive radiotherapy with similar policies, and their doses of radiotherapy and treatment volumes are determined by the site and stage of the disease. Patients in the "treatment arm" receive 200 units/kg/day of r-HuEPO, subcutaneously, five times a week with iron (Fe SO4, 325 mg. p.o., t.i.d.) supplements. Complete blood counts are obtained weekly. Quality of life is assessed weekly by the patients themselves by a few simple entries on an analog scale. RESULTS Twenty-six patients have been entered in the study so far. Twelve patients were placed in the control arm and 14 in the treatment arm. Pre-randomization demographic and laboratory mean values in both arms were comparable, with none of 16 parameters compared reaching statistical significance. Our results can be summarized as follows: (a) Mean hemoglobin, hematocrit, and red blood cell values increased gradually in the treatment arm patients. Week-by-week comparison showed that mean values for these three parameters were significantly higher in the treatment arm than in the control arm. For example, the p values for the differences in hemoglobin mean values for weeks 1-6 were 0.015, 0.002, 0.003, 0.0002, 0.0006, and 0.007, respectively. Similar trends were observed for red blood cells and the hematocrit values. (b) No significant toxicity has been encountered. (c) No significant differences in the mean values of white blood cells and platelet counts were seen between the two arms. The values of these two parameters declined over the course of radiotherapy. (d) The mean weekly increase in hemoglobin levels in the treatment arm was 0.43 gm/dl. CONCLUSION (a) The safety and efficacy of r-HuEPO, with 200 units/kg/day of subcutaneous administration, have been confirmed in our study group. (b) However, the rate of increase in hemoglobin levels is not very rapid with the doses used. (c) Dose escalation studies are needed for determination of the feasibility of improving hemoglobin levels by about 1 gm/dl/week. (d) The question whether improvement in hemoglobin with r-HuEPO therapy can improve outcome by improving tumor oxygenation needs to be studied in carcinoma of the uterine cervix and squamous cell carcinoma of the head and neck.
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Affiliation(s)
- S Vijayakumar
- Dept. of Radiation and Cellular Oncology, Michael Reese/University of Chicago, IL
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36
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Swift PS, Phillips T, Martz K, Wara W, Mohiuddin M, Chang CH, Asbell SO. CT characteristics of patients with brain metastases treated in RTOG study 79-16. Int J Radiat Oncol Biol Phys 1993; 25:209-14. [PMID: 8420868 DOI: 10.1016/0360-3016(93)90341-r] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [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: 01/30/2023]
Abstract
The search continues for a favorable subgroup of patients with brain metastases in whom testing of new modalities might show a benefit in overall survival. Complete pre- and post-treatment CT evaluation of the brain was performed in 779 of the 859 patients entered into RTOG protocol 7916, a phase III study of the role of misonidazole combined with radiation therapy in the treatment of brain metastases. Pretreatment scan findings of mass effect, midline shift, massive edema, central necrosis, location of sentinel lesion, and number of lesions were correlated with length of survival for all patients as well as for each treatment group. The only characteristics that showed a statistically significant difference in survival in the overall group were the presence of < or = 3 lesions and the presence of a midline shift. The actual benefit in overall survival, however, was found to be only 3 weeks. The volume of the largest lesion prior to treatment did not correlate well with survival, nor did location of lesions. The time to response, number of responders and absolute decrease in number of lesions were similar for the four treatment arms. Patients who responded to cranial treatment had a significantly prolonged survival over those who did not respond. No CT characteristic evaluated in this study showed value as a clinically relevant prognosticator for patients with brain metastases for the overall group. Patients who fulfilled three of the four favorable clinical characteristics previously described by Diener-West (age < or = 60, KPS > or = 70, primary lesion absent or controlled and brain as sole site of metastasis), were analyzed separately. Those with < or = three lesions had a statistically significantly prolonged survival over those with four or more lesions.
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Affiliation(s)
- P S Swift
- Dept. of Radiation Oncology, UCSF Medical Center 94143
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Abstract
We describe our preliminary experience with a beta-test version of the Leksell Gamma Plan (LGP) treatment planning system. During this testing phase we used the LGP system to find an acceptable treatment plan and then transferred coordinates to the KULA system for final calculation. We find that the LGP system offers a fast way of optimizing shot placement and weighting, especially for complex treatments. The ability to display many MR and CT images on screen and to superimpose isodose lines on these images, as soon as the dose distribution has been calculated, allows adjustments to be made more rapidly than with the plotting approach used by the KULA system. This software is in beta-test, and is undergoing modification. Problems relating to our hardware configuration have been addressed with a newer workstation specified for the production system.
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Affiliation(s)
- V Smith
- University of California, San Francisco
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38
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Abstract
The effect of two cranial radiation (CRTX) doses and the time since radiation therapy on cognitive functioning were studied in 35 children who completed therapy for acute lymphoblastic leukemia (ALL). The patients were grouped according to CRTX dose (2400 or 1800 cGy) and evaluated for general intelligence, academic achievement, and visual motor integration. Those who received 2400 cGy (n = 20) scored ten points below those treated with 1800 cGy (n = 15) on verbal intelligence quotient and achievement tests of reading, spelling, and arithmetic. The effect of time since radiation therapy on these measures of cognitive function was significant (P = 0.001 to 0.03); the effect of CRTX dose was not. Visual motor integration scores in both groups fell below the 33rd percentile. The effect of CRTX dose and time since radiation therapy on visual motor integration and performance intelligence quotient were not significant. Thus, the interval between treatment and the emergence of cognitive impairments may be longer after lower CRTX doses, and deficits in nonverbal areas such as visual motor integration may appear first. A larger study is needed to confirm these findings from a limited sample of long-term survivors of ALL.
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Affiliation(s)
- I M Moore
- College of Nursing, University of Arizona, Tucson
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Evans AE, Jenkin RD, Sposto R, Ortega JA, Wilson CB, Wara W, Ertel IJ, Kramer S, Chang CH, Leikin SL. The treatment of medulloblastoma. Results of a prospective randomized trial of radiation therapy with and without CCNU, vincristine, and prednisone. J Neurosurg 1990; 72:572-82. [PMID: 2319316 DOI: 10.3171/jns.1990.72.4.0572] [Citation(s) in RCA: 386] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In a prospective randomized trial designed to study the effectiveness of adjuvant chemotherapy following standard surgical treatment and radiation therapy, 233 eligible patients with medulloblastoma were treated by members of the Children's Cancer Study Group and the Radiation Therapy Oncology Group. Eligible patients were randomly assigned to receive radiation therapy with or without adjuvant chemotherapy consisting of 1-(2-chloroethyl)-3-cyclohexyl-nitrosourea (CCNU), vincristine, and prednisone. The estimated 5-year event-free survival probability was 59% for patients treated with radiation therapy and chemotherapy and 50% for patients treated with radiation therapy alone, a difference which is not statistically significant. The 5-year survival probability was 65% for both groups. Although the treatment difference was not statistically significant when all patients were combined, in the small number of patients with more extensive tumors, event-free survival was better in the group receiving chemotherapy (48% vs. 0%, p = 0.006). In these latter patients the survival time is also significantly prolonged. Extent of disease (as measured by the M staging criteria described by Chang) and age at diagnosis were significantly associated with outcome; advanced disease and young age had a worse prognosis. The extent of tumor resection was not an independent prognostic factor. It is concluded that chemotherapy does not benefit patients with low-stage medulloblastoma, but may benefit those with more advanced stages of disease.
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Affiliation(s)
- A E Evans
- Children's Hospital of Philadelphia, Pennsylvania
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40
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Linstadt D, Larson D, Edwards M, Prados M, Wara W. Hyperfractionated irradiation for adults with brainstem gliomas. Int J Radiat Oncol Biol Phys 1990. [DOI: 10.1016/0360-3016(90)90806-u] [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: 11/25/2022]
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41
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Sposto R, Ertel IJ, Jenkin RD, Boesel CP, Venes JL, Ortega JA, Evans AE, Wara W, Hammond D. The effectiveness of chemotherapy for treatment of high grade astrocytoma in children: results of a randomized trial. A report from the Childrens Cancer Study Group. J Neurooncol 1989; 7:165-77. [PMID: 2550594 DOI: 10.1007/bf00165101] [Citation(s) in RCA: 228] [Impact Index Per Article: 6.5] [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: 01/01/2023]
Abstract
Fifty-eight patients with high-grade astrocytoma were treated by members of the Childrens Cancer Study Group in a prospective randomized trial designed to study the effectiveness of chemotherapy as an adjuvant to standard surgical treatment and radiotherapy. Following surgical therapy, patients were assigned randomly to radiotherapy with or without chemotherapy consisting of chloroethyl-cyclohexyl nitrosourea, vincristine, and prednisone. Treatment with chemotherapy prolonged survival and event-free survival. Five-year event-free survival was 46% for patients in the radiotherapy and chemotherapy group, and 18% for patients in the radiotherapy-alone group. Five-year survival was similarly improved. The differences in outcome due to treatment were statistically significant after correcting for imbalances in important prognostic factors (event-free survival, p = 0.026; survival, p = 0.067). The presence of mitoses or necrosis in the tumor specimen was associated with poorer outcome. Patients whose initial surgery was limited to biopsy, and patients with basal ganglia lesions, also had significantly worse outcome. Chemotherapy administered at the time of recurrence in a small number of patients did not produce any long-term survivors. This study is to our knowledge the only randomized trial to investigate effectiveness of chemotherapy in the treatment of high-grade astrocytoma in children.
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Affiliation(s)
- R Sposto
- University of Southern California School of Medicine, Los Angeles
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42
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Abstract
Six cases of histologically proven pineocytoma are reported. The diagnosis was established by surgery in five cases and at autopsy in one. All patients received focal radiation therapy (4500 to 5400 cGy). Two patients had local recurrences at 1 and 48 months and subsequently died of tumor. A third patient died of Alzheimer's disease 29 years after the initial presentation. Three patients are alive with no evidence of disease at 21+, 52+, and 84+ months after treatment. Tumor dissemination occurred after a local recurrence in one patient. We found no evidence of recurrence outside the irradiated field unless there was an initial recurrence at the primary tumor site. We recommend postoperative staging for all patients with pineocytoma and focal radiation therapy if local disease alone is found. Craniospinal radiation therapy appears to be justified only if tumor dissemination is documented on staging tests.
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Affiliation(s)
- A Disclafani
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco
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Levin VA, Rodriguez LA, Edwards MS, Wara W, Liu HC, Fulton D, Davis RL, Wilson CB, Silver P. Treatment of medulloblastoma with procarbazine, hydroxyurea, and reduced radiation doses to whole brain and spine. J Neurosurg 1988; 68:383-7. [PMID: 3343610 DOI: 10.3171/jns.1988.68.3.0383] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Forty-seven patients with medulloblastoma were treated postoperatively with procarbazine, followed by craniospinal radiation therapy in combination with hydroxyurea. The radiation dose to the posterior fossa was 55 Gy; the spinal cord received 25 Gy and the whole brain 25 to 35 Gy (mean 33 Gy). Seventeen tumors recurred. Only one initial recurrence was in the spinal subarachnoid space; 10 (59%) were in the posterior fossa, and four (24%) were supratentorial. The estimated 5-year disease-free survival probability was 55%; the 5-year overall survival rate was 66%. Myelotoxicity occurred in 38% of patients, but in only one case was it severe enough to warrant reducing the total dose of radiation. It was concluded that good-risk medulloblastoma patients may be treated with radiation dosages as low as 25 Gy to the spinal axis and to the whole brain without increasing the risk of recurrence outside the posterior fossa. Chemotherapy with procarbazine followed by radiation therapy and hydroxyurea during radiation therapy was well tolerated and may play a role in reducing radiation dosages outside the posterior fossa.
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Affiliation(s)
- V A Levin
- Department of Neurological Surgery, University of California, San Francisco
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Abstract
Primary central nervous system non-Hodgkin's lymphomas are observed in approximately 1.9% of all patients with acquired immunodeficiency syndrome (AIDS). The yearly incidence of AIDS-associated tumors has surpassed the yearly incidence from all other causes and could become as frequent as low-grade astrocytomas by 1991. Patients' signs, symptoms, and radiographic studies are not specific for this lesion; brain biopsy usually is necessary to make a definitive diagnosis. Most tumors are high-grade lymphomas and are pathologically similar to the primary central nervous system lymphomas observed before the AIDS epidemic. AIDS-associated tumors respond readily to radiation therapy. However, patient survival remains limited owing to other manifestations of the syndrome.
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Affiliation(s)
- M L Rosenblum
- Department of Neurosurgery, University of California, San Francisco 94143
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Jenkin RD, Boesel C, Ertel I, Evans A, Hittle R, Ortega J, Sposto R, Wara W, Wilson C, Anderson J. Brain-stem tumors in childhood: a prospective randomized trial of irradiation with and without adjuvant CCNU, VCR, and prednisone. A report of the Childrens Cancer Study Group. J Neurosurg 1987; 66:227-33. [PMID: 3806204 DOI: 10.3171/jns.1987.66.2.0227] [Citation(s) in RCA: 127] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Seventy-four children with a brain-stem tumor diagnosed between 1977 and 1980 were entered into a prospective study in which exploration and assessment for resection were optional, radiation treatment using standard methods was required, and randomization occurred with regard to the use of adjuvant chemotherapy (1-(2-chloroethyl)-1-nitrosourea, vincristine, and prednisone) or no further treatment. The overall 5-year survival rate was 20% and was not improved by the adjuvant chemotherapy program. An increased risk of infection was associated with the adjuvant therapy.
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Leibel S, Gutin P, Phillips T, Wara W, Choucair A, Weaver K, Lamb S, Silver P, Barnett C. Improved survival following interstitial implantation of removable high-activity iodine-125 sources for malignant recurrent gliomas. Int J Radiat Oncol Biol Phys 1986. [DOI: 10.1016/0360-3016(86)90608-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Allen JC, Bloom J, Ertel I, Evans A, Hammond D, Jones H, Levin V, Jenkin D, Sposto R, Wara W. Brain tumors in children: current cooperative and institutional chemotherapy trials in newly diagnosed and recurrent disease. Semin Oncol 1986; 13:110-22. [PMID: 3513315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Temoshiok L, Van Raalte G, Farrell D, Geiser M, Wara W. Group interventions for breast cancer patients undergoing radiation therapy: A descriptive study. Int J Radiat Oncol Biol Phys 1982. [DOI: 10.1016/0360-3016(82)90335-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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