Predictors of prolonged treatment time intervals in oral cavity cancer

OBJECTIVES

Delays in treatment time intervals have been associated with overall survival in oral cavity squamous cell carcinoma (OCSCC). The aim of this study was to identify bottlenecks leading to prolonged treatment intervals.

MATERIAL AND METHODS

A retrospective analysis was conducted using a cohort of OCSCC patients who underwent surgery and adjuvant radiation therapy. The endpoints of interest were prolonged treatment intervals. Multivariable logistic regression was used to adjust for patient and tumour characteristics.

RESULTS

Median diagnosis-to-treatment interval (DTI) and surgery to initiation of postoperative radiation therapy interval (S-PORT) were 39 days (IQR 30-54) and 64 days (IQR 54-66), respectively. Prolonged DTI was associated with older age, worse Charlson Comorbidity index scores and worse T stages. Patients with prolonged DTI had longer times to preoperative imaging reports (25 vs 9 days; P < 0.01). Time to preoperative pathology did not differ. Prolonged S-PORT was associated with longer times to pathology report (28 vs 18 days; P < 0.01), to maxillofacial consult (38 vs 15 days; P < 0.01) and to maxillofacial approval of radiation (50 vs 28 days; P < 0.01). In patients requiring medical oncology consults, those with prolonged S-PORT had longer waiting times until consultation (58 vs 38 days; P = 0.02). Multivariate analysis showed independent predictors of prolonged DTI: time to preoperative imaging; and prolonged S-PORT: time to pathology report, time to maxillofacial consult, and time to medical oncology consult.

CONCLUSIONS

Strategies targeting these organizational bottlenecks may be effective for shortening treatment time intervals, hence representing potential opportunities for improving oncological outcomes in OCSCC patients.

Bullous Pemphigoid-Associated Mortality Rate in a Canadian Tertiary Referral Centre

BACKGROUND

Bullous pemphigoid (BP) is the most common autoimmune blistering disorder in adults. Most individuals with BP are over the age of 60. Its worldwide incidence has been increasing owing to population aging. Observational studies published over the last 2 decades highlight the non-negligible, albeit variable overall mortality of BP patients, with reported 12-month mortality rates of 10.8% to 40.8%, and 24-month mortality rates of 20.1% to 51.0%. Data in the Canadian population are lacking.

OBJECTIVES

We aimed to estimate the 12- and 24-month overall mortality rate of Canadian patients diagnosed with BP, and to identify independent risk factors adversely impacting overall survival.

METHODS

A retrospective cohort study of 166 patients with a diagnosis of BP between 2010 and 2020 was carried out at Centre hospitalier de l'Université de Montréal (CHUM), a tertiary referral center in Montréal, Québec, Canada. Cumulative mortality was calculated using the Kaplan-Meier estimator, and independent prognostic factors were identified using a Cox proportional hazards regression model.

RESULTS

Eighty-five patients (51.2%) in our study were female. The median age was 79.1 years old, and 80 patients (48.2%) were 80 years old or older. Mortality at 12 and 24 months in our study cohort was 16.2% (CI95% = 10.5 - 21.8) and 27.6% (CI95% = 20.5 - 34.7), respectively. In a multivariate analysis, patients who were male, 80 years old or older, and/or had a diagnosis of a major neurocognitive disorder had a poorer overall survival.

CONCLUSIONS

The all-cause mortality of patients with BP in our study population compared favorably with international data reported in the literature.

Frameless Stereotactic Radiosurgery With Linear Accelerator (LINAC)-Based Technology for Brain Metastases: Outcomes Analysis in 141 Patients

Objectives Brain metastases (BM) are the most common intracranial tumors in adults. Surgery and frame-based stereotactic radiosurgery (SRS) are well-described treatment options. Frameless SRS is an emerging BM treatment option offering fewer side effects. The aim of this study was to describe the therapeutic outcomes and toxicity of frameless SRS with linear accelerator (LINAC)-based technology for BM treatment in our institution. Materials and methods We performed a retrospective study including all adult patients treated with frameless SRS with LINAC-based technology for BM between October 2010 and July 2016. Patients were followed routinely with MRI scans at three-month intervals. Primary endpoints were progression-free survival, local control, overall survival, and toxicity related to the treatment. All survival times were computed with the Kaplan-Meier method. All cumulative incidences were computed using competing risk analyses. Results A total of 194 metastatic lesions in 141 patients were treated in a 69-month interval. At the time of analysis, 33 patients were still alive, with a median follow-up time of 25.1 months. The overall median survival was 8.7 months. The median progression-free survival was 5.3 months. Local recurrence as a first event was 25% and 38% at one and two years, respectively, while distant brain recurrence as a first event was 18% and 21%. Death before any brain event occurred in 31% of patients. The cumulative incidence of radiation necrosis as a first brain event was 2% at one and two years. Conclusions The treatment of BM with LINAC-based frameless SRS in our institution had an overall and progression-free survival comparable with the literature for frameless SRS and for conventional frame-based SRS while being less invasive and more comfortable for the patient. In our study, frameless SRS with LINAC technology seems to be safe for BM treatment with minimal rates of radiation necrosis.

Abstract P4-12-07: Single pre-operative radiation therapy (SPORT) trial for low risk breast cancer: A phase 1 study comparing pathological findings in immediate versus delayed surgery

Introduction: Estrogen receptor (ER)-positive/HER2-negative breast cancers are known to be less immunogenic than triple negative and HER2-positive breast cancers. As increasing levels of tumor-infiltrating lymphocytes (TILs) have been associated with increased rates of pathological complete response (pCR) and improved prognosis, there is interest in exploring ways to render ER-positive/HER2-negative breast cancers more immunogenic. Few studies have analysed the histological response to neoadjuvant radiation therapy (RT) as the only pre-operative treatment modality; in most case series, chemotherapy was concomitantly given, as these studies focused on the treatment of advanced breast cancer. Aims: The objectives of this study are to assess pathological and immunological responses induced by a single dose of pre-operative RT in early breast cancer. Material and methods: women aged 60 years or older diagnosed with invasive breast carcinoma were prospectively identified. Only cT1N0 unifocal tumors that were low to intermediate grade and ER-positive/HER2 negative were eligible. Patients received a single pre-operative radiation dose of 20Gy in a single fraction. Surgery was performed either 24-72 hours after RT (SPORT group) or 11-13 weeks after RT (SPORT -DS [delayed surgery] group). Assessment of pathological response was performed using the Miller-Payne system and Residual Cancer Burden was calculated. Immunohistochemistry for Ki67 was performed on the biopsy and excision specimens. CD8 immunostain was used to evaluate the immune infiltrate. Both groups (SPORT and SPORT-DS) were compared using the independent t-test and Fisher exact test. Results: a total of thirteen patients were included, with an average age of 73 years (range 60-84). All patients received a single 20Gy radiation dose, and surgery was performed either 24-72 hours after RT (SPORT group, n=5) or on average 95 days after RT in the SPORT-DS group (range 75-133 days; n=8). All patients underwent partial mastectomy with sentinel lymph node biopsy. Histologically, all tumors were invasive ductal carcinomas, except for one invasive micropapillary carcinoma and one invasive tubular carcinoma (both in the SPORT group). Tumor bed changes, similar to what is observed in the post-neoadjuvant chemotherapy setting, were identified in all but one patients in the SPORT-DS group (7/8 patients) but was not seen in the SPORT group (0/5 patients, p=0.005). Using the Miller-Payne system, there was no evidence of response in the SPORT cohort (grade 1/5 in all patients), while 6/8 patients in the SPORT-DS cohort had a partial pathological response (grade 3/5 in 2 patients and grade 4/5 in 4 patients, p = 0.02). No pCR were observed. Comparing Ki67 on the biopsy and surgical specimens, an average decrease of 7.5% in the SPORT group and 6.3% in the SPORT-DS group was observed (p=0.8). A significant lymphocytic infiltrate was not present in any case (stromal TILs &lt;10% in all cases). At an average follow-up of 11 months, there have been no recurrences. Conclusion: This is, to our knowledge, the first series comparing histological findings from immediate and delayed surgery after pre-operative single dose RT. We observed a significant decrease in tumor cellularity with delayed surgery, while no change in cellularity occurred with immediate surgery. The lack of lymphocytic infiltrate does not support immune activation as the mechanism of the ablative effect of 20Gy of radiation. Further follow-up will be needed to determine the prognostic significance of the partial pathological response that was observed in the SPORT-DS cohort.

Citation Format: Marie-Hélène Ngo, David Tiberi, Peter Vavassis, David Nguyen, Bernard Fortin, Mai-Kim Gervais, Lucas Sideris, Pierre Dubé, Guy Leblanc, Michel-Pierre Dufresne, Marie-Christine Guilbert, Michael Yassa. Single pre-operative radiation therapy (SPORT) trial for low risk breast cancer: A phase 1 study comparing pathological findings in immediate versus delayed surgery [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-12-07.

Are radiation oncologists following guidelines? An audit of practice in patients with uncomplicated bone metastases

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At our center single fraction radiotherapy is used in accordance with guidelines.

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Patient age, performance status and tumor histology influence treatment choice.

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We added a quality indicator to our performance dashboard to improve adherence.

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This strategy can be used in other complex practices and improve quality of care.

Background

Best-practice guidelines recommend single-fraction (SFRT) instead of multi-fraction radiation therapy (MFRT) for uncomplicated symptomatic bone metastases. SFRT is comparable to MFRT in relieving pain, convenient for patients, and cost-effective. Patterns of practice in Canada reveal that SFRT is underused, with significant variability across the country. We audited SFRT use and studied factors that may influence treatment decisions at a large academic tertiary care center in Quebec, Canada.

Methods

Patients who received radiotherapy for uncomplicated bone metastases between February 2014 and March 2015 were reviewed. Age, gender, primary histology, site of metastases and performance status were identified as potential factors affecting fractionation. These were explored by Fisher's test on univariate analysis and logistic regression for multivariate analysis. Retreatment rates were analyzed with cumulative incidence and compared with Gray's test.

Results

254 radiotherapy courses were administered to 165 patients, 85.4% of which were delivered using a single fraction of 8 Gy. Patients age less than 70 years and those with breast histology were more likely to receive MFRT (p = 0.04; p = 0.0046). Performance status (ECOG) was a significant predictor of fractionation because of high correlations between young age, breast histology, and ECOG status (p = 0.03). Follow-up was too short in 40% of patients to derive definitive conclusions on retreatment.

Conclusions

In accordance with current guidelines, our audit confirms that use of SFRT in patients with uncomplicated bone metastases at our center is high. We identified that patient age, primary histology, and performance status influenced fractionation. Incorporation of this quality indicator into our performance dashboard will allow assessment of retreatment differences and other criteria that may also influence treatment choice.

Peer effects, fast food consumption and adolescent weight gain

This paper aims at opening the black box of peer effects in adolescent weight gain. Using Add Health data on secondary schools in the U.S., we investigate whether these effects partly flow through the eating habits channel. Adolescents are assumed to interact through a friendship social network. We propose a two-equation model. The first equation provides a social interaction model of fast food consumption. To estimate this equation we use a quasi maximum likelihood approach that allows us to control for common environment at the network level and to solve the simultaneity (reflection) problem. Our second equation is a panel dynamic weight production function relating an individual's Body Mass Index z-score (zBMI) to his fast food consumption and his lagged zBMI, and allowing for irregular intervals in the data. Results show that there are positive but small peer effects in fast food consumption among adolescents belonging to a same friendship school network. Based on our preferred specification, the estimated social multiplier is 1.15. Our results also suggest that, in the long run, an extra day of weekly fast food restaurant visits increases zBMI by 4.45% when ignoring peer effects and by 5.11%, when they are taken into account.

Physician payment mechanisms, hospital length of stay and risk of readmission: evidence from a natural experiment

We provide an analysis of the effect of physician payment methods on their hospital patients' length of stay and risk of readmission. To do so, we exploit a major reform implemented in Quebec (Canada) in 1999. The Quebec Government introduced an optional mixed compensation (MC) scheme for specialist physicians working in hospital. This scheme combines a fixed per diem with a reduced fee for services provided, as an alternative to the traditional fee-for-service system. We develop a model of a physician's decision to choose the MC scheme. We show that a physician who adopts this system will have incentives to increase his time per clinical service provided. We demonstrate that as long as this effect does not improve his patients' health by more than a critical level, they will stay more days in hospital over the period. At the empirical level, we estimate a model of transition between spells in and out of hospital analog to a difference-in-differences approach. We find that the hospital length of stay of patients treated in departments that opted for the MC system increased on average by 4.2% (0.28 days). However, the risk of readmission to the same department with the same diagnosis does not appear to be overall affected by the reform.

Xerostomia in patients treated for oropharyngeal carcinoma: comparing linear accelerator-based intensity-modulated radiation therapy with helical tomotherapy

BACKGROUND

In comparison to sliding-window intensity-modulated radiation therapy (sw-IMRT), we hypothesized that helical tomotherapy (HT) would achieve similar locoregional control and, at the same time, decrease the parotid gland dose, thus leading to a xerostomia reduction.

METHODS

The association between radiation techniques, mean parotid dose, and xerostomia incidence, was reviewed in 119 patients with advanced oropharyngeal carcinoma treated with concurrent chemoradiation using sw-IMRT (n = 59) or HT (n = 60).

RESULTS

Ipsilateral and contralateral parotid mean doses were significantly lower for patients treated with HT versus sw-IMRT: 24 Gy versus 32 Gy ipsilaterally and 20 Gy versus 25 Gy contralaterally. The incidence of grade ≥2 xerostomia was significantly lower in the HT group than in the sw-IMRT group: 12% versus 78% at 6 months, 3% versus 51% at 12 months, and 0% versus 25% at 24 months. Total parotid mean dose <25 Gy was strongly associated to a lower incidence of grade ≥2 xerostomia at 6, 12, and 24 months.

CONCLUSION

This retrospective series suggests that using HT can better spare the parotid glands while respecting quantitative analysis of normal tissue effects in the clinic (QUANTEC)'s criteria.

Hypofractionated radiation therapy for breast ductal carcinoma in situ

PURPOSE

Conventional radiation therapy (RT) administered in 25 fractions after breast-conserving surgery (BCS) is the standard treatment for ductal carcinoma in situ (DCIS) of the breast. Although accelerated hypofractionated regimens in 16 fractions have been shown to be equivalent to conventional RT for invasive breast cancer, few studies have reported results of using hypofractionated RT in DCIS.

METHODS AND MATERIALS

In this multicenter collaborative effort, we retrospectively reviewed the records of all women with DCIS at 3 institutions treated with BCS followed by hypofractionated whole-breast RT (WBRT) delivered in 16 fractions.

RESULTS

Between 2003 and 2010, 440 patients with DCIS underwent BCS followed by hypofractionated WBRT in 16 fractions for a total dose of 42.5 Gy (2.66 Gy per fraction). Boost RT to the surgical bed was given to 125 patients (28%) at a median dose of 10 Gy in 4 fractions (2.5 Gy per fraction). After a median follow-up time of 4.4 years, 14 patients had an ipsilateral local relapse, resulting in a local recurrence-free survival of 97% at 5 years. Positive surgical margins, high nuclear grade, age less than 50 years, and a premenopausal status were all statistically associated with an increased occurrence of local recurrence. Tumor hormone receptor status, use of adjuvant hormonal therapy, and administration of additional boost RT did not have an impact on local control in our cohort. On multivariate analysis, positive margins, premenopausal status, and nuclear grade 3 tumors had a statistically significant worse local control rate.

CONCLUSIONS

Hypofractionated RT using 42.5 Gy in 16 fractions provides excellent local control for patients with DCIS undergoing BCS.

P4-18-04: Hypofractionated Radiotherapy for Breast Ductal Carcinoma In Situ

Background

Conventional radiotherapy at a dose of 50 Gy in 25 fractions after breast conservative surgery is the standard treatment for ductal carcinoma in situ of the breast (DCIS). Hypofractionation is an interesting alternative for the treatment of breast cancer, providing a less intense treatment scheme for the patient. While the hypofractionated regimen of 42.5 Gy in 16 fractions has been shown to be equivalent to 50 Gy in 25 in infiltrating ductal carcinoma, few studies and no prospective study have reported results using hypofractionation in DCIS.

Materials and Methods: In this multicenter collaborative effort, we retrospectively reviewed the records of women with a diagnosis of DCIS at two Canadian institutions, treated with conservative surgery followed by hypofractionated radiotherapy (42.5 Gy in 16 fractions) to the whole breast. Tumor, patient and treatment factors were collected. Local control was evaluated using the Kaplan Meier method. Curves were compared using log rank.

Results: Between 2003 to 2008, 292 patients with DCIS underwent conservative surgery followed by hypofractionated radiation in 16 fractions for a total dose of 42.5 Gy. Treatment delivery was similar at both institutions. Mean age at diagnosis was 59 years, with 70 % of women being postmenopausal. Nuclear grade was 1–2 in 65 % of patients while 28 % had grade 3 tumors. Complete surgical excision with negative margins was achieved in 92 % of patients. Radiotherapy boost was given to 92 patients (31.5 %) at the discretion of the radiation oncologist. After a mean follow up of 3.35 years (range 1–8 years), 10 patients (3.4 %) had ipsilateral local relapse resulting in a disease-free survival (DFS) of 96 % at 4 years. The histology at recurrence was DCIS for 8 patients; infiltrative disease for one patient and one patient had an unknown histology at recurrence. Age was statistically associated with local relapse (DFS 89 % for patients under 50 years old vs 97 % for those older than 50, p=0.027). Grade was also a significant prognostic factor (DFS 98% for grade 1–2 vs 91 % for grade 3, p = 0.015). Finally, administration of boost did not have an impact on local control (DFS boost 98 % vs 95 % for no boost, p=0.44).

Discussion: Hypofractionated radiotherapy (42.5 Gy in 16 fractions) provides excellent local control for patients with DCIS undergoing breast conservative surgery. This regimen is more convenient to both patient and physician since it is less time consuming. Further work needs to be done to determine if this regimen is as effective as conventional radiotherapy in younger women (age less than 50) and those with grade 3 tumors.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-18-04.

Toxicity report of once weekly radiation therapy for low-risk prostate adenocarcinoma: preliminary results of a phase I/II trial

Background

Increasing clinical data supports a low α/β ratio for prostate adenocarcinoma, potentially lower than that of surrounding normal tissues. A hypofractionated, weekly radiation therapy (RT) schedule should result in improved tumour control, reduced acute toxicity, and similar or decreased late effects. We report the toxicity profile of such treatment.

Materials and Methods

We conducted a multi-institution phase I/II trial of three-dimensional conformal radiation therapy (3D-CRT) for favourable-risk prostate cancer (T1a-T2a, Gleason ≤ 6 and PSA < 10 ng/ml). RT consisted of 45 Gy in nine 5 Gy fractions, once weekly. Primary end-points were feasibility and late gastrointestinal (GI) toxicity (RTOG scale), while secondary end-points included acute GI toxicity, acute and late genitourinary (GU) toxicity, biochemical control, and survival.

Results

Between 2006 and 2008, 80 patients were treated. No treatment interruptions occurred. The median follow-up is 33 months (range: 20-51). Maximal grade 1, 2, and 3 acute (< 3 months) GU toxicity was 29%, 31% and 5% respectively (no grade 4). Acute GI grade 1 toxicity was reported in 30% while grade 2 occurred in 14% (no grade 3 or 4). Crude late grade ≥ 3 toxicity rates at 31 months were 2% for both GU and GI toxicity. Cumulative late grade ≥ 3 GI toxicity at 3 years was 11%. Two patients had PSA failure according to the Phoenix definition. The three-year actuarial biochemical control rate is 97%.

Conclusions

Weekly RT with 45 Gy in 9 fractions is feasible and results in comparable toxicity. Long term tumour control and survival remain to be assessed.

Cervical lymph node metastases from unknown primary cancer: a single-institution experience with intensity-modulated radiotherapy

PURPOSE

To determine the effectiveness and rate of complications of intensity-modulated radiotherapy (IMRT) in the treatment of cervical lymph node metastases from unknown primary cancer.

METHODS AND MATERIALS

Between February 2005 and November 2008, 25 patients with an unknown primary cancer underwent IMRT, with a median radiation dose of 70 Gy. The bilateral neck and ipsilateral putative pharyngeal mucosa were included in the target volume. All patients had squamous cell carcinoma, except for 1 patient who had adenosquamous differentiation. They were all treated with curative intent. Of the 25 included patients, 20 were men and 5 were women, with a median age of 54 years. Of these patients, 3 had Stage III, 18 had Stage IVa, and 4 had Stage IVb. Of the 25 patients, 18 (72%) received platinum-based chemotherapy in a combined-modality setting. Neck dissection was reserved for residual disease after definitive IMRT. Overall survival, disease-free survival, and locoregional control were calculated using the Kaplan-Meier method.

RESULTS

With a median follow-up of 38 months, the overall survival, disease-free survival, and locoregional control rates were all 100% at 3 years. No occurrence of primary cancer was observed during the follow-up period. The reported rates of xerostomia reduced with the interval from the completion of treatment. Nine patients (36%) reported Grade 2 or greater xerostomia at 6 months, and only 2 (8%) of them reported the same grade of salivary function toxicity after 24 months of follow-up.

CONCLUSION

In our institution, IMRT for unknown primary cancer has provided good overall and disease-free survival in all the patients with an acceptable rate of complications. IMRT allowed us to address the bilateral neck and ipsilateral putative pharyngeal mucosa with minimal late salivary function toxicity. The use of concurrent chemotherapy and IMRT for more advanced disease led to good clinical results with reasonable toxicities.

Simultaneous integrated boost using intensity-modulated radiotherapy compared with conventional radiotherapy in patients treated with concurrent carboplatin and 5-fluorouracil for locally advanced oropharyngeal carcinoma

PURPOSE

To compare, in a retrospective study, the toxicity and efficacy of simultaneous integrated boost using intensity-modulated radiotherapy (IMRT) vs. conventional radiotherapy (CRT) in patients treated with concomitant carboplatin and 5-fluorouracil for locally advanced oropharyngeal cancer.

METHODS AND MATERIALS

Between January 2000 and December 2007, 249 patients were treated with definitive chemoradiation. One hundred patients had 70 Gy in 33 fractions using IMRT, and 149 received CRT at 70 Gy in 35 fractions. Overall survival, disease-free survival, and locoregional control were estimated using the Kaplan-Meier method.

RESULTS

Median follow-up was 42 months. Three-year actuarial rates for locoregional control, disease-free survival, and overall survival were 95.1% vs. 84.4% (p = 0.005), 85.3% vs. 69.3% (p = 0.001), and 92.1% vs. 75.2% (p < 0.001) for IMRT and CRT, respectively. The benefit of the radiotherapy regimen on outcomes was also observed with a Cox multivariate analysis. Intensity-modulated radiotherapy was associated with less acute dermatitis and less xerostomia at 6, 12, 24, and 36 months.

CONCLUSIONS

This study suggests that simultaneous integrated boost using IMRT is associated with favorable locoregional control and survival rates with less xerostomia and acute dermatitis than CRT when both are given concurrently with chemotherapy.

Quality of life and tumor control after short split-course chemoradiation for anal canal carcinoma

PURPOSE

To evaluate quality of life (QOL) and outcome of patients with anal carcinoma treated with short split-course chemoradiation (CRT).

METHODS

From 1991 to 2005, 58 patients with anal cancer were curatively treated with CRT. External beam radiotherapy (52 Gy/26 fractions) with elective groin irradiation (24 Gy) was applied in 2 series divided by a median gap of 12 days. Chemotherapy including fluorouracil and Mitomycin-C was delivered in two sequences. Long-term QOL was assessed using the site-specific EORTC QLQ-CR29 and the global QLQ-C30 questionnaires.

RESULTS

Five-year local control, colostomy-free survival, and overall survival were 78%, 94% and 80%, respectively. The global QOL score according to the QLQ-C30 was good with 70 out of 100. The QLQ-CR29 questionnaire revealed that 77% of patients were mostly satisfied with their body image. Significant anal pain or fecal incontinence was infrequently reported. Skin toxicity grade 3 or 4 was present in 76% of patients and erectile dysfunction was reported in 100% of male patients.

CONCLUSIONS

Short split-course CRT for anal carcinoma seems to be associated with good local control, survival and long-term global QOL. However, it is also associated with severe acute skin toxicity and sexual dysfunction. Implementation of modern techniques such as intensity-modulated radiation therapy (IMRT) might be considered to reduce toxicity.

ERCC1 polymorphism in patients with locally advanced head and neck squamous cell carcinoma treated with concomitant chemoradiation: Prevalence and impact on treatment efficacy

6032

Background: Excision repair cross-complementation group 1 (ERCC1) is a gene coding for the nucleotide excision repair complex. Its increased expression and polymorphism at codon 118 have been linked to poor response to chemotherapy or chemoradiation in several types of cancer. ERCC1 removes the cisplatin adducts on the DNA of cells and its polymorphism appears to be a marker of chemotherapeutic resistance to platinum-based therapy. Objectives: To determine the prevalence of the polymorphism of ERCC1 (codon 118) in patients with locally advanced HNSCC treated with concomitant platinum-based chemoradiation therapy with or without prior surgery, and its effect on eficacy evaluated by locoregional control, disease-free survival and overall survival. Methods: Prospective data on efficacy was available on 460 consecutive patients treated with concomitant chemoradiation in our institution with a minimal follow-up of 2 years. Of these, 230 fixed and paraffin embedded biopsies or surgical specimens were collected. DNA was extracted from specimens and polymorphism of codon 118 was determined using a PCR technique. All analysis were performed using Kaplan-Meier survival curves, Fisher's test for categorical data and log-rank statistics for failure times. Results: DNA extraction was successful in 222 patients. Polymorphism mapping was possible in 178 specimens. Genotypic distribution in the population was the following : AAT/AAT:40% (Gr1), AAC/AAT: 48%(Gr2), AAC/AAC: 12% (Gr3). At 3 years, evaluation of efficacy for Gr1, Gr2, and Gr3 was determined. Locoregional control was respectively 77%, 83%, and 67% (p = NS), DFS was 58%, 68% and 55% (p=NS), and OS was 70%, 69%, and 70% (p = NS). Conclusions: ERCC1 polymorphism did not have an impact in our population on response to chemoradiation therapy. It can be postulated that ERCC1 does not seem to discriminate patients for whom another treatment option should be sought for patients with locally advanced SCCHN. Further data will be presented at the meeting including a multivariate analysis using different markers tested in our laboratory (KRAS, MGMT methylation, etc).

No significant financial relationships to disclose.

Higher dose per fraction and shorter overall treatment time using intensity-modulated radiation therapy versus conventional radiation therapy with concurrent carboplatin and 5-fluorouracil for locally advanced oropharyngeal carcinoma: A comparison of toxicity and efficacy

6038

Background: The aim of this retrospective study was to compare toxicity and efficacy of two different radiotherapy regimens, the first one using intensity-modulated radiation therapy (IMRT) to that of conventional radiotherapy (CRT) in patients treated with concomitant chemotherapy for locally advanced oropharyngeal cancer. Methods: Between January 2000 and December 2007, 249 patients with stage III-IV squamous cell oropharyngeal carcinoma were treated at our institution with definitive concurrent chemoradiation using carboplatin 70 mg/m2/day for four days and 5-fluorouracil 600 mg/m2/day as a continuous infusion every 3 weeks. One hundred patients had 70 Gy in 33 fractions using IMRT (2.12 Gy per day) and 149 received CRT at 70 gy in 35 fractions (2 Gy per day), both administered five times a week. Toxicities were compared using Fisher's exact test. Overall survival (OS), disease-free survival (DFS), and locoregional control (LRC) were estimated using the Kaplan-Meier method and compared with the log-rank test. Results: Median follow-up was 33 months. Three year actuarial rates for OS, DFS, and LRC were 95.4 vs. 75.8% (p < 0.001), 89.3 vs. 71.6% (p < 0.001), and 92.4 vs. 85.3% (p = 0.050) for IMRT and CRT respectively. To minimize the effect of changes in treatment paradigm over time, analyses were performed for patients treated after January 2004 and still showed OS, DFS, and LRC differences. Comparison of toxicities demonstrated that IMRT was associated with fewer dermatitis than CRT (p < 0.01), but caused the same rates of mucositis, weight loss, enteral feeding, hospitalization and death during treatment. There was significantly less xerostomia at 24 and 36 months (p < 0.001) following the end of treatment with IMRT. Conclusions: In this retrospective study, higher dose per fraction and shorter overall treatment time using IMRT given concurrently with chemotherapy when compared to CRT is a safe regimen with better OS, DFS, LRC, and less long term xerostomia. Altered fractionation RT with chemotherapy seems to result in better outcome and future prospective trials are needed to confirm this hypothesis.

No significant financial relationships to disclose.

Impact of massage therapy on anxiety levels in patients undergoing radiation therapy: randomized controlled trial

Anxiety is a major issue in the cancer patient population. This randomized phase III trial evaluated the effects of massage therapy on anxiety levels in patients undergoing radiation therapy. Patients undergoing radiation therapy were randomly assigned to either 10 massage sessions or control sessions. Anxiety levels were evaluated throughout the course of treatment using both the visual analogue scale (VAS) and the State-Trait Anxiety Inventory (STAI). The immediate effect of massage therapy on anxiety scores was measured via pre- and postmassage VAS scores. The intermediate-term effect of massage was assessed through the VAS scores over the 10 sessions and STAI scores at the last session. The trial's primary outcome was the difference in intermediate-term anxiety scores, whereas the secondary outcome was the difference in immediate anxiety scores. Between January 2006 and June 2006, 100 patients were randomized. After their massage, the patients' immediate postmassage anxiety score according to the VAS was reduced by an average of 45% compared with their premassage score (p < .001). No impact of massage therapy on intermediate-term anxiety scores was observed. Both groups showed a similar decline in VAS anxiety scores from the first to the last session, that is, 15% and 19% in the massage therapy and control groups, respectively (p = .73). Furthermore, no difference was observed between the groups' respective state-anxiety scores after the 10 sessions. Massage therapy is associated with a significant, immediate decrease in anxiety scores. However, massage therapy appears to have no major impact on intermediate-term anxiety in patients undergoing radiation therapy.

Physicians' multitasking and incentives: empirical evidence from a natural experiment

We analyse how physicians respond to contractual changes and incentives within a multitasking environment. In 1999 the Quebec government (Canada) introduced an optional mixed compensation (MC) system, combining a fixed per diem with a partial (relative to the traditional fee-for-service (FFS) system) fee for services provided. We combine panel survey and administrative data on Quebec physicians to evaluate the impact of this change in incentives on their practice choices. We highlight the differentiated impact of incentives on various dimensions of physician behaviour by considering a wide range of labour supply variables: time spent on seeing patients, time devoted to teaching, administrative tasks or research, as well as the volume of clinical services and average time per clinical service. Our results show that, on average, the reform induced physicians who changed from FFS to MC to reduce their volume of (billable) services by 6.15% and to reduce their hours of work spent on seeing patients by 2.57%. Their average time spent per service increased by 3.81%, suggesting a potential quality-quantity substitution. Also the reform induced these physicians to increase their time spent on teaching and administrative duties (tasks not remunerated under the fee-for-service system) by 7.9%.

Neck dissection following concurrent chemoradiation for advanced head and neck carcinoma: pathologic findings and complications

OBJECTIVE

To assess the rate of pathologic residual neck disease and complication rates following selective neck dissection in patients with advanced head and neck carcinoma after concurrent chemotherapy (CT) and radiation therapy (RT).

PATIENTS AND METHODS

Two hundred sixty-four patients with advanced-stage head and neck carcinoma underwent concurrent CT and RT from 1998 to 2004 at Notre-Dame Hospital. We describe the outcome of 32 of these patients who underwent neck dissections at our institution. The median age was 56 years (35-73 years). The primary sites were the oropharynx (n = 25), followed by the larynx (n = 3), hypopharynx (n = 1), and oral cavity (n = 1), and there were two unknown primary sites. The initial neck stages were 2 N1, 19 N2, and 11 N3. The known primary sites were staged 2 T1, 10 T2, 8 T3, 10 T4, and 2 Tx. All patients received conventional RT to a dose of 70 Gy in 35 fractions concurrent with a platinum-based CT regimen

RESULTS

The median follow-up was 20 months. The mean operative blood loss for neck dissections alone was 170 mL (SD = 158.3 mL), the mean operative time was 128 minutes (SD = 41.6 minutes), and the mean hospital stay was 3.6 days (SD = 1.7 days). There were no major surgical complications. Five minor complications were noted in four patients (12.5%). Twelve patients (38%) had pathologic evidence of persistent disease (1 of 2 N1, 7 of 19 N2, and 4 of 11 N3).

CONCLUSIONS

Cervical neck dissection is a safe procedure following concurrent CT and RT and is still indicated if there is clinical or radiologic evidence of disease persistence in the neck. We experienced no major surgical complications and few minor complications. The pathologic residual rate was 38%.