Health-related quality of life in men with oligometastatic prostate cancer following metastases-directed stereotactic body radiotherapy: Real-world data from the E2-RADIatE OligoCare cohort

Objective

To evaluate the impact of metastases-directed stereotactic body radiotherapy (SBRT) on health-related quality of life (HRQoL) in men with oligometastatic prostate cancer (PCa) using real-world data from the OligoCare cohort.

Materials and methods

OligoCare is a pragmatic, observational cohort designed to assess the impact of metastases-directed SBRT on patients with oligometastatic disease (OMD). We report an interim analyses of the secondary endpoint HRQoL, assessed using the EORTC QLQ-C30, within six months of metastases-directed SBRT for oligometastatic disease in men with PCa among the first 1600 registered patients. HRQoL data collection was optional within the OligoCare cohort. To compare HRQoL between baseline and first follow-up assessment, a Wilcoxon signed-rank test was used. A multiple linear regression model was used to explore the HRQoL associations with predefined factors.

Results

Out of the 1600 registered patients, 658 were treated for oligometastatic PCa, of which 233 had baseline QoL data and 132 patients had both baseline and follow-up HRQoL data. At baseline, most patients had a WHO performance status of 0 or 1 (87 %), were de-novo oligometastatic (79 %), had one metastasis (90 %), and had a good overall global health status (mean 80.81, SD16.11, IQR 75-92). 51 % received hormonal therapy as concomitant systemic treatment. Patients with comorbidities as assessed by the Charlson Comorbidity index had a worse global health status at baseline (-4.88, 95 % CI:-9.35, -0.42). No clinically meaningful significant difference in global health status was observed at first assessment following SBRT (median 3.0 months) compared with baseline (mean difference 2.27, 95 % CI:-1.54, 6.08). Upon evaluating the proportions, meaningful clinically important differences (a 10-point or more difference) was observed in, 17 % and 11 % of the patients reporting deterioration and improvement of global health status, respectively.

Conclusion

Metastases-directed stereotactic body radiotherapy had no negative impact on global HRQoL within the first six months after treatment.

Safety of CDK4/6 inhibitors and concomitant radiation therapy in patients affected by metastatic breast cancer

PURPOSE

Cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) currently represent the standard of care for the initial treatment of patients with metastatic hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) breast cancer. The aim of our study is to evaluate the safety of the use of concomitant radiation therapy (RT) in a consecutive series of HR+/HER2- patients treated in two academic institutions with CDK4/6i in the metastatic setting.

METHODS AND MATERIALS

From September 2017 to February 2020, we retrospectively collected and analysed data on a sequential series of patients treated with CDK4/6i, receiving RT or not, at two European institutions. Primary outcome of the study was the association between RT and any adverse events (AEs) ≥ G3. Secondary outcomes were the association between RT and any AEs (any grade), CDK4/6i dose reduction rate, and CDK4/6i treatment discontinuation rate.

RESULTS

We analysed a total of 132 consecutive women; RT was prescribed in 57 (43.2%) patients (70 irradiated lesions). The median age of the series was 52.1 years (range 32.3-78.2). Concomitant RT administration was not significantly related to higher AEs ≥ G3 (p = 0.19) and any grade AEs (p = 1.0); there was no association with RT and CDK4/6i dose reduction (p = 0.49) and discontinuation rates (p = 0.14). At a median follow-up of 18.8 months, the progression-free survival (PFS) rate was 35% and the overall survival (OS) rate was 38.7% in the whole group. The use of concomitant RT did not affect both PFS (p = 0.71) and OS rates (p = 0.55).

CONCLUSIONS

Our data are encouraging regarding the safety of this combination, showing that concurrent RT did not increase severe toxicity and did not have an impact on systemic treatment conduction.

Economic and social impacts of COVID-19 and public health measures: results from an anonymous online survey in Thailand, Malaysia, the UK, Italy and Slovenia

OBJECTIVES

To understand the impact of COVID-19 and public health measures on different social groups, we conducted a mixed-methods study in five countries ('SEBCOV-social, ethical and behavioural aspects of COVID-19'). Here, we report the results of the online survey.

STUDY DESIGN AND STATISTICAL ANALYSIS

Overall, 5058 respondents from Thailand, Malaysia, the UK, Italy and Slovenia completed the self-administered survey between May and June 2020. Poststratification weighting was applied, and associations between categorical variables assessed. Frequency counts and percentages were used to summarise categorical data. Associations between categorical variables were assessed using Pearson's χ2 test. Data were analysed in Stata 15.0 RESULTS: Among the five countries, Thai respondents reported having been most, and Slovenian respondents least, affected economically. The following factors were associated with greater negative economic impacts: being 18-24 years or 65 years or older; lower education levels; larger households; having children under 18 in the household and and having flexible/no income. Regarding social impact, respondents expressed most concern about their social life, physical health, mental health and well-being.There were large differences between countries in terms of voluntary behavioural change, and in compliance and agreement with COVID-19 restrictions. Overall, self-reported compliance was higher among respondents who self-reported a high understanding of COVID-19. UK respondents felt able to cope the longest and Thai respondents the shortest with only going out for essential needs or work. Many respondents reported seeing news perceived to be fake, the proportion varying between countries, with education level and self-reported levels of understanding of COVID-19.

CONCLUSIONS

Our data showed that COVID-19 and public health measures have uneven economic and social impacts on people from different countries and social groups. Understanding the factors associated with these impacts can help to inform future public health interventions and mitigate their negative consequences.

TRIAL REGISTRATION NUMBER

TCTR20200401002.

A fatal wound complication following sequential anti-angiogenesis, immune checkpoint inhibition and ultra-hypofractionated radiotherapy

PURPOSE

Multimodality treatments combining radiotherapy, immune therapy and/or targeted therapy are under heavy investigation. Promising data from clinical trials are emerging, nevertheless unexpected interactions and adverse events should not be overlooked.

CASE PRESENTATION

Here we present a case study of a patient with metastatic colon adenocarcinoma treated sequentially with a chemotherapy/targeted therapy combination, immune checkpoint inhibitors and ultra-hypofractionated radiotherapy. After radiation treatment, the patient developed extensive posterior abdominal wall wounds coinciding with regression of the irradiated metastatic tumour mass and marked elevation of the inflammation parameters.

CONCLUSION

This case represents an unusual fatal wound complication after palliative ultra-hypofractionated radiotherapy. Further research into synergistic effects of sequential radiotherapy and anti-angiogenesis therapy may provide an advantage in anticipating severe sequelae.

Telemedicine in Radiation Oncology Post-COVID-19 Pandemic: There Is No Turning Back

PURPOSE

We aimed to assess patients' and physicians' perspectives on wider implementation of telemedicine in radiation oncology practice, disrupted by the novel coronavirus disease 2019 (COVID-19).

METHODS

Quantitative questionnaires were prepared and distributed between May 27 and June 11, 2020. A 29-question survey targeting patients with cancer was distributed electronically via cancer support organizations. Cross-sectional data from a selected weekday at a radiation oncology department were also analyzed. In addition, a 25-question survey was distributed to 168 physicians employed by a comprehensive cancer center.

RESULTS

In total, we have analyzed 468 patients' and 101 physicians' responses. Among responding patients, 310 were undergoing active treatment and 158 were in follow-up care. Both patients and physicians reported no experiences with video consultations during the COVID-19 pandemic, but 15% of patients stated that they missed telemedicine services that would include a video call. Overall, 30.6% of patients expressed interest in more frequent usage of telemedicine and 23.3% would start using it. Sixty-seven percent of radiation oncologists expressed interest in more frequent usage of telemedicine, and 14% would use it similarly as in the past. For patients treated with radiation therapy (RT), 59.9% and 63.4% of the responding patients acknowledged that video consultations would be an important addition to medical care during RT course or after the completion of RT, respectively. Comparably, 61.1% and 63.9% of radiation oncologists believed video consultations would be useful or extremely useful for patients undergoing RT or for patients in the follow-up setting, respectively.

CONCLUSIONS

The post-COVID-19 era represents a unique chance to improve and guarantee continuity of cancer care via telemedicine solutions, when appropriate.

Cyclin-Dependent Kinase 4/6 Inhibitors Combined With Radiotherapy for Patients With Metastatic Breast Cancer

BACKGROUND

The cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) represent the standard treatment for hormone receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer. Data about the balance between efficacy and toxicity of combined palliative radiotherapy (RT) and CDK4/6 inhibition are lacking.

PATIENTS AND METHODS

We undertook a review of 46 patients with metastatic breast cancer on systemic treatment with CDK4/6i who underwent 62 metastases-directed RT. Clinical, laboratory, and RT treatment planning data were collected. Statistical analyses included Student t test, paired sample t test, and logistic regression modeling.

RESULTS

Thirty patients (65.2%) received palbociclib, 15 (32.6%) received ribociclib, and one patient received abemaciclib (2.2%). Median total prescribed RT dose was 20 Gy (range, 8-63 Gy). Sites of RT were bone (n = 50; 80.7%), visceral (n = 7; 11.3%), or brain metastases (n = 3; 4.8%), as well as primary tumor of the breast (n = 2; 3.2%). Overall, the rates of grade 3 or higher adverse events (AEs) were 6.5%, 4.3%, 15.2%, and 23.9% before the start of RT, during RT, 2 and 6 weeks after RT completion, respectively. We found no correlation between dose distribution to organs at risk and the development of AEs. The local control rates for the entire cohort were 98% at 6 months and 90% at 12 months. Overall, pain relief (complete or partial) was experienced by 80% (24/30) of patients who initially reported pain at the treated metastatic site.

CONCLUSION

We observed a modest increase in the rates of grade 3 or higher AEs after combined RT and CDK4/6i, with maintained efficacy of concomitant RT.

End-of-life decisions in 34 Slovene Intensive Care Units: a nationwide prospective clinical study

BACKGROUND

The aim of this study was to determine how end-of-life decisions (EOLD) on limitations of life-sustaining treatment (LST) are made in three different types of intensive care units (ICUs) in Slovenia.

METHODS

A national multicenter prospective study among 31 adult and three pediatric/neonatal ICUs (PICUs). The questionnaire form on EOLD was designed to assess the clinical practice. Data were collected between January 1, 2013, and March 31, 2013. For statistical analysis we used IBM® SPSS® Statistics 20 software package.

RESULTS

Overall, of 4226 patients were admitted to ICUs, the EOLD on limitation of LST were performed in 112 patients (23.9%) out of 468 patients, which had died and/or had been subject to EOLD on limitation of LST. In 86.2% of the cases, patients had impaired competence. Advance directives were available only in 1.9% (2 out of 106 patients) of the cases. In the majority of cases, the EOLD was taken by the physicians (96.2%). In 61.8% of the cases, patient representatives were involved in the discussion about limitation of LST. The do-not-resuscitate order and withholding of inotropes/vasopressors were the most common measures to limit LST. Most commonly withdrawn were inotropes/vasopressors and antibiotics. Palliative care was included in 72.3% of the cases (80 out of 112 patients), however, palliative care team was only included in 4% of the cases.

CONCLUSIONS

No differences were found between the three different types of ICUs in EOLD on limitation of LST even though limitation of LST was provided regularly. The most commonly limited LST measures include mechanical ventilation, inotropes/vasopressors, hemodialysis, and antibiotics. Almost none of the patients had advance directives in place. Palliative care team was available in only few cases.

Attitudes of Slovene paediatricians to end-of-life care

AIMS

The aims of this study were to assess the attitudes of Slovene paediatricians to aspects of end-of-life (EOL) care and compare these attitudes between paediatric intensivists, paediatric specialists and paediatric residents.

METHODS

We performed a cross-sectional survey, using a specifically designed 43-item anonymous questionnaire.

RESULTS

We included 323 out of 586 Slovene paediatricians and residents, while 46.7% (151 of 323) of them responded to our questionnaire. More than half of intensivists (54.2%) had sought counsel from the Committee for Medical Ethics in the past as compared with 12.0% and 12.1% of specialists and residents, respectively (P < 0.001). The decision to limit life-sustaining treatment (LST) was found to be ethically acceptable in all groups of respondents. The highest level of agreement was found in residents (90.2%), followed by 83.3% among intensivists and 73.8% among specialists (P = not statistically significant (NS)). Disagreement with termination of hydration was highest among residents (85%) and intensivists (79.2%) while it was lower among specialists (66.7%) (P = NS). Patient's best interest, good clinical practice and patient's autonomous decision were graded as the top three aspects of the EOL care, while cost effectiveness and availability of patient's bed in intensive care were the least important.

CONCLUSIONS

The decision to limit LST measures was found to be ethically acceptable for Slovene paediatricians. No major differences were found among paediatric intensivists, specialist paediatricians and paediatric residents in the attitudes towards the EOL care.

Experiences of Slovene ICU physicians with end-of-life decision making: a nation-wide survey

Background

Advances in intensive care medicine have enormously improved ability to successfully treat seriously ill patients. However, intensive treatment and prolongation of life is not always in the patient’s best interest, and many ethical dilemmas arise in end-of-life (EOL) situations. We aimed to assess intensive care unit (ICU) physicians’ experiences with EOL decision making and to compare the responses according to ICU type.

Material/Methods

A cross-sectional survey was performed in all 35 Slovene ICUs, using a questionnaire designed to assess ICU physician experiences with EOL decision making, focusing on limitations of life-sustaining treatments (LST).

Results

We distributed 370 questionnaires (approximating the number of Slovene ICU physicians) and 267 were returned (72% response rate). The great majority of ICU physicians reported using do-not-resuscitate (DNR) orders (97%), withholding LST (94%), and withdrawing antibiotics (86%) or inotropes (95%). Fewer ICU physicians reported withdrawing mechanical ventilation (52%) or extubating patients (27%). Hydration was reported to be only rarely terminated (76% of participants reported never terminating it). In addition, 63% of participants had never encountered advance directives, and 39% reported to “never” or “rarely” participating in decision making with relatives of patients. Nurses were reported to be “never” or “rarely” involved in the EOL decision making process by 84% of participants.

Conclusions

Limitation of LST was regularly used by Slovene ICU physicians. DNR orders and withholding of LST were the most commonly used measures. Hydration was only rarely terminated. In addition, use of advance directives was almost non-existent in practice, and the patients’ relatives and nurses only infrequently participated in the decision making.