Improving Patient Compliance with Vaginal Dilator Therapy by Implementation of Sexual Health Consult in Gynecologic Malignancies after Radiation Therapy

PURPOSE/OBJECTIVE(S)

Typical vaginal dilator therapy (VDT) compliance falls short at approximately 30% of patients in reported studies, which could lead to vaginal stenosis (VS) in as high as 88% of patients who undergo radiation therapy (RT) for gynecologic malignancies. In an ongoing effort to improve adherence to VDT aimed to prevent vaginal stenosis post pelvic and vaginal RT, a prospective study was implemented to assess the feasibility and the impact on vaginal dilator therapy adherence when implementing a consult with the oncology women's sexual health clinic following the completion of radiation therapy.

MATERIALS/METHODS

This was a single institution, prospective analysis and feasibility study that included patients diagnosed with a gynecologic cancer who were treated with RT to the pelvic and or vaginal tissues. Using purposive sampling, the treating radiation oncologists identified eligible patients and referred them to the oncology women's sexual health clinic for consult four to six weeks status post completion of RT in a six-month period. A post treatment survey was conducted via a telephone interview 12 weeks after the sexual health clinic initial consult to assess vaginal dilator therapy compliance. Descriptive statistics were calculated.

RESULTS

Pre-intervention retrospective data analysis revealed poor compliance to VDT with only 3 of 40 (7.5%) patients judged as compliant. Post-intervention, 30 of 37 (81.1%) patients in the sample were judged compliant. The adherence rate in the post-intervention group was significantly higher (Fisher's Exact Test two-tailed p-value < 0.0001). With confidence of 95%, the proportion of the potential population that would adhere post intervention was between 68.5% and 93.7%. Sociodemographic and clinical characteristics did not have a statistically significant correlation with VDT compliance.

CONCLUSION

Implementing a referral to an oncology women's sexual health clinic at the completion of RT for the sample population is feasible. Our project demonstrates that instituting this new sexual health clinic may have a large, positive impact on patient compliance to vaginal dilator therapy. More importantly, this may lead to decrease incidences of vaginal stenosis and improvement in patient health outcomes and quality of life (QoL).

Intraoperative radiation therapy for early-stage breast cancer: a single-institution experience

Background

To assess outcomes and toxicity after low-energy intraoperative radiotherapy (IORT) for early-stage breast cancer (ESBC).

Materials and methods

We reviewed patients with unilateral ESBC treated with breast-conserving surgery and 50-kV IORT at our institution. Patients were prescribed 20 Gy to the surface of the spherical applicator, fitted to the surgical cavity during surgery. Patients who did not meet institutional guidelines for IORT alone on final pathology were recommended adjuvant treatment, including additional surgery and/or external-beam radiation therapy (EBRT). We analyzed ipsilateral breast tumor recurrence, overall survival, recurrence-free survival and toxicity.

Results

Among 201 patients (median follow-up, 5.1 years; median age, 67 years), 88% were Her2 negative and ER positive and/or PR positive, 98% had invasive ductal carcinoma, 87% had grade 1 or 2, and 95% had clinical T1 disease. Most had pathological stage T1 (93%) N0 (95%) disease. Mean IORT applicator dose at 1-cm depth was 6.3 Gy. Post-IORT treatment included additional surgery, 10%; EBRT, 11%; adjuvant chemotherapy, 9%; and adjuvant hormonal therapy, 74%. Median total EBRT dose was 42.4 (range, 40.05–63) Gy and median dose per fraction was 2.65 Gy. At 5 years, the cumulative incidence of ipsilateral breast tumor recurrence was 2.7%, the overall survival rate was 95% with no breast cancer-related deaths, and the recurrence-free survival rate was 96%. For patients who were deemed unsuitable for postoperative IORT alone and did not receive recommended risk-adapted EBRT, the IBTR rate was 4.7% versus 1.7% (p = 0.23) for patients who were either suitable for IORT alone or unsuitable and received adjuvant EBRT. Cosmetic toxicity data was available for 83%, with 7% experiencing grade 3 breast toxicity and no grade 4–5 toxicity.

Conclusions

IORT for select patients with ESBC results in acceptable outcomes in regard to ipsilateral breast tumor recurrence and toxicity.

A Prospective Randomized Trial of the Influence of Music on Anxiety in Patients Starting Radiation Therapy for Cancer

PURPOSE

One of the most downloaded articles in 2017 from the International Journal of Radiation Oncology, Biology, and Physics was a study suggesting that music therapy during radiation therapy (RT) simulation substantially reduces anxiety. To further evaluate the potential of music's clinical efficacy in the context of radiation therapy, we conducted a randomized trial evaluating the influence of genre-based music chosen by the study participant on anxiety during the first RT treatment session with a method that is applicable to routine clinical practice.

METHODS AND MATERIALS

We conducted a prospective randomized trial of music versus no music during the first RT treatment for cancer. We limited the study to women because prior studies document a higher rate of anxiety in female patients with cancer. Anxiety was evaluated before and after the first RT treatment using the State-Trait Anxiety Inventory (STAI) and Symptom Distress Thermometer (SDT). Patients randomized to music had their preferred genre of music played from a web-based application while in the treatment vault.

RESULTS

In the study, 102 females were enrolled (51 with and 51 without music). Baseline high anxiety score before RT was recorded in 48% of patients using the STAI and 58% using the SDT. The percent decrease in mean STAI score was 16% with music versus 10% without music (P = .2197). The mean SDT percent changes were a 13% decrease with music versus a 2% increase without music (P = .3298).

CONCLUSIONS

This study documents that high anxiety is common in women receiving RT for cancer and that music, as used in this study, does not reduce anxiety to a meaningful degree.

Radiotherapy for Adult Soft Tissue Sarcomas of the Head and Neck

OBJECTIVE

Surgery followed by postoperative radiation therapy (RT) is the standard of care for soft tissue sarcomas (STS) of the head and neck that are high grade or have close or positive margins.

METHODS

The authors retrospectively reviewed adult patients with head and neck STS treated with RT at a single institution between 1981 and 2017. All patients who were 19 years and older with STS of the head and neck-excluding rhabdomyosarcoma, angiosarcoma, and Ewing tumors-were included in this study. Toxicity was graded using Common Terminology Criteria for Adverse Events (CTCAE), version 4.

RESULTS

Among 34 patients with head and neck STS treated with postoperative RT (33) or primary RT (1) who met the inclusion criteria, the median age at diagnosis was 45 years (range, 20 to 83). Overall, 37% had T1 tumors, 50% had high-grade histology (grade 3), and 26% had microscopically positive margins. The median RT dose was 65 Gy to the primary site; 29% received elective nodal irradiation. The median follow-up for living patients was 16.6 years (range, 0.6 to 30). At 5 and 10 years, the local control rates were 88% and 80%, the regional control rates were 97% and 97%, the freedom from distant metastases rates were 100% and 100%, the cause-specific survival rates were 88% and 81%, and the overall survival rates were 85% and 69%. Two patients (6%) developed late grade 3+ complications.

CONCLUSION

Our study demonstrates that surgery and radiotherapy for STS of the head and neck have excellent disease outcomes.

Pulmonary Function after Proton Therapy for Hodgkin Lymphoma

Purpose:

Acute and late toxicity from chemotherapy, targeted therapy, and radiation therapy can cause significant morbidity among survivors of Hodgkin lymphoma (HL), including pulmonary dysfunction. Improved dosimetry may influence pulmonary function tests (PFTs), an objective and clinically significant measure of pulmonary toxicity. The present study investigates the impact of proton therapy on PFTs among HL survivors.

Patients and Methods:

We monitored 15 patients with mediastinal HL who were enrolled in an institutional HL trial. All patients were treated with combination chemotherapy plus involved-node proton therapy. All patients were to undergo PFTs before starting treatment and at approximately 6 and 12 months after completing proton therapy.

Results:

Twelve patients were included in the analysis and 3 excluded. The mean forced vital capacity (FVC) was 96.2% ± 16.5% (mean ± SD) predicted at baseline and 98.2% ± 19.4% predicted at 12 months. The mean forced expiratory volume in 1 second (FEV₁) was 96.7% ± 17.2% predicted at baseline and 97% ± 15.1% predicted at 12 months. The mean FEV₁/FVC ratio was 99.5 ± 8.29 at baseline and 97.8 ± 8.02 at 12 months. The mean diffusing capacity of the lung for carbon monoxide was 81.4% ± 18.4% predicted at baseline and 95.7% ± 23.5% predicted at 12 months.

Conclusion:

No unexpected changes were observed to the lungs as illustrated through follow-up PFTs. Long-term follow-up and validation in a larger cohort are needed.

Advances in the management of craniopharyngioma

Craniopharyngioma is a curable benign tumor, but owing to its intimate relationship to critical structures in the central brain—such as the optic apparatus, pituitary, hypothalamus, intracranial vasculature, brain stem, and temporal lobes—its management introduces the risk of long-term treatment morbidity. Today, the most common treatment approach is conservative subtotal resection followed by radiotherapy, and the goal is to limit long-term toxicity. Many recent advances in the treatment of craniopharyngioma are attributable to improved surgical techniques and radiotherapy technologies.

Pertuzumab and trastuzumab infusion related cytokine release syndrome in a chemotherapy naive patient with metastatic breast cancer

Pertuzumab is a monoclonal antibody that targets and down regulates HER-2/neu expression in ductal breast tumors. Other HER-2/neu monoclonal antibodies, particularly trastuzumab, have been implicated to induce infusion related reactions such as cytokine release syndrome (CRS). Here, we report a case of pertuzumab associated CRS prior to infusion of trastuzumab which warranted hospitalization for symptom management.