Talking with clinicians about online cancer information: a survey of cancer patients and surrogate information seekers

OBJECTIVES

To describe patients' and surrogate information seekers' experiences talking to clinicians about online cancer information. To assess the impact of clinicians telling patients or surrogate seekers not to search for information online.

DESIGN

Cross-sectional survey.

SAMPLE

A total of 282 participants, including 185 individuals with cancer and 97 surrogate seekers.

METHODS

Individuals were recruited through a broad consent registry and completed a 20-min survey.

FINDINGS

Cancer patients and surrogate seekers did not differ significantly in their experiences talking with clinicians about online cancer information. Nearly all patients and surrogate seekers who were told by a clinician not to go online for cancer information did so anyway.

IMPLICATIONS

Interventions for improving cancer information seeking and communication with clinicians should target both patients and surrogate seekers. Clinicians should be educated about effective ways to communicate with patients and surrogate seekers about online cancer information.

Validation of the Combined Clinical Cell-Cycle Risk Score to Prognosticate Early Prostate Cancer Metastasis From Biopsy Specimens and Comparison With Other Routinely Used Risk Classifiers

PURPOSE

We aim to independently validate the prognostic utility of the combined cell-cycle risk (CCR) multimodality threshold to estimate risk of early metastasis after definitive treatment of prostate cancer and compare this prognostic ability with other validated biomarkers.

METHODS

Patients diagnosed with localized prostate cancer were enrolled into a single-institutional registry for the prospective observational cohort study. The primary end point was risk of metastasis within 3 years of diagnostic biopsy. Secondary end points included time to definitive treatment, time to subsequent therapy, and metastasis after completion of initial definitive treatment. Multivariable cause-specific Cox proportional hazards regression models were produced accounting for competing risk of death and stratified on the basis of the CCR active surveillance and multimodality (MM) thresholds. Time-dependent areas under the receiver operating characteristic curve were calculated.

RESULTS

The cohort consisted of 554 men with prostate cancer and available CCR score from biopsy. The CCR score was prognostic for metastasis (hazard ratio [HR], 2.32 [95% CI, 1.17 to 4.59]; P = .02), with scores above the MM threshold having a higher risk than those below the threshold (HR, 5.44 [95% CI, 2.72 to 10.91]; P < .001). The AUC for 3-year risk of metastasis on the basis of CCR was 0.736. When men with CCR above the MM threshold received MM therapy, their 3-year risk of metastasis was significantly lower than those receiving single-modality therapy (3% v 14%). Similarly, a CCR score above the active surveillance threshold portended a faster time to first definitive treatment.

CONCLUSION

CCR outperforms other commonly used biomarkers for prediction of early metastasis. We illustrate the clinical utility of the CCR active surveillance and multimodality thresholds. Molecular genomic tests can inform patient selection and personalization of treatment for localized prostate cancer.

Multi-Institutional Analysis of Cancer Patient Exposure, Perceptions, and Trust in Information Sources Regarding Complementary and Alternative Medicine

PURPOSE

Complementary and alternative medicine (CAM) use during cancer treatment is controversial. We aim to evaluate contemporary CAM use, patient perceptions and attitudes, and trust in various sources of information regarding CAM.

METHODS

A multi-institutional questionnaire was distributed to patients receiving cancer treatment. Collected information included respondents' clinical and demographic characteristics, rates of CAM exposure/use, information sources regarding CAM, and trust in each information source. Comparisons between CAM users and nonusers were performed with chi-squared tests and one-way analysis of variance. Multivariable logistic regression models for trust in physician and nonphysician sources of information regarding CAM were evaluated.

RESULTS

Among 749 respondents, the most common goals of CAM use were management of symptoms (42.2%) and treatment of cancer (30.4%). Most CAM users learned of CAM from nonphysician sources. Of CAM users, 27% reported not discussing CAM with their treating oncologists. Overall trust in physicians was high in both CAM users and nonusers. The only predictor of trust in physician sources of information was income >$100,000 in US dollars per year. Likelihood of trust in nonphysician sources of information was higher in females and lower in those with graduate degrees.

CONCLUSION

A large proportion of patients with cancer are using CAM, some with the goal of treating their cancer. Although patients are primarily exposed to CAM through nonphysician sources of information, trust in physicians remains high. More research is needed to improve patient-clinician communication regarding CAM use.

Paging Dr. Google: Characterizing Direct to Consumer Internet Advertisements from Oncology Treatment Centers

PURPOSE/OBJECTIVE(S)

Patients increasingly use internet searches to compare treatment options and decide on oncology treatment centers. The objective of this study is to examine the type of oncology treatment centers that were advertised on web-based searches.

MATERIALS/METHODS

A series of keyword searches were conducted using the Google search engine. Based on search trends, 3 of the top relevant search phrases were used ("best cancer doctor", "best cancer treatment", and "cancer treatment near me"). Modifiers were added to each search term to reflect the cancer categories with the highest prevalence: "breast", "prostate", and "lung". This yielded 12 search phrases that were used on a search hub that simulates Google searches from different geographic locations. The 30 most populous city locations were used. Of the four paid advertisements at the top of each search, the cancer treatment centers were categorized into centers that are National Cancer Institute-Designated (NCIs), Commission on Cancer (CoC) accredited, non-CoC accredited, and non-traditional treatment centers. Advertisements that weren't for cancer treatment centers were excluded.

RESULTS

Of the 360 searches and 817 subsequent cancer treatment center advertisements, 51.2% were for NCI, 12.2% were CoC accredited, 26.9% were non-CoC accredited, and 9.7% were non-traditional treatment centers. The search phrase that yielded the highest ratio of NCI results was "best cancer doctor" at 74.4% and the phrase that yielded the lowest was "prostate cancer treatment near me" at 37.1%. Of the known 71 NCI centers in the country, 42 (59.2%) did not have any advertisements. Of the 35 NCI centers located in one of the target cities, 12 (34.3%) did not have any advertisements. Notably, two specific NCI centers accounted for 49.5% of the NCI advertisements. Similarly, one specific non-traditional treatment center accounted for 48.1% of the non-traditional center advertisements. Regarding non-traditional treatment centers, there was geographic variation with Boston having 38.1% of searches yielding non-traditional treatment center advertisements as opposed to six cities having 0%. The ratio of non-traditional treatment center advertisements by region were as follows: Northeast with 13.6%, West with 12.6%, South with 7.7%, and Midwest with 5.0%.

CONCLUSION

These results indicate that most direct-to-consumer cancer advertisements come from CoC or NCI centers. Among advertisements coming from NCI centers, relatively few centers account for the majority of advertisements with most NCI centers having no advertising presence. Future research is needed to evaluate claims, costs, and the ethical considerations of direct-to-consumer marketing, where the potential for mischaracterizing the strength of the scientific evidence to vulnerable cancer populations requires more scrutiny.

Delay in Time to Oncologic Therapies for Patients with Positive COVID-19 Test

PURPOSE/OBJECTIVE(S)

For several cancers, delays between diagnosis and initiation of treatment has important clinical implications, often affecting trial eligibility, treatment intention, and oncologic outcomes. The coronavirus disease-19 (COVID-19) pandemic placed an extraordinary strain on the United States healthcare system, and its effect on oncologic patterns of care has yet to be established. We hypothesize that patients who received a new cancer diagnosis and subsequently tested positive for COVID-19 had delayed oncologic treatment compared to those who did not test positive for COVID-19.

MATERIALS/METHODS

The National Cancer Database (NCDB) was queried to identify patients who were diagnosed and treated for any of 10 common malignancies from 2019-2020. Included disease sites were head and neck, esophagus, rectum, anus, lung, breast, cervix, uterus, prostate, and primary brain. Those who tested positive for COVID-19 between time of diagnosis and first oncologic treatment (including surgery, radiation, or systemic therapy) were compared to those who did not test positive for COVID-19. COVID-19 positivity was assessed using a new variable in the NCDB, "SARSCOV2_POS," which captures whether patients received a positive COVID-19 test via reverse transcriptase-polymerase chain reaction testing in inpatient, outpatient, or emergency room settings in 2020. Duration in days from cancer diagnosis to time to first treatment (TTFT) was analyzed using two-sample t-tests, with significance level of p<0.05.

RESULTS

A total of 1,503,127 patients were identified for analysis. Of these, 7,340 (0.5%) tested positive for COVID-19 between diagnosis and start of treatment. Initial treatment was most commonly surgery (55.3%), followed by systemic therapy (17.4%) and radiation (12.7%). Overall, median TTFT was 55 days [interquartile range (IQR) 31-91] for the COVID-19 group versus 34 days (IQR 15-56) for the non-COVID-19 group (p <0.01). Subgroup analysis of the 10 individual sites of disease revealed statistically significant delays in each, with greatest absolute difference in median TTFT in prostate (31.5 days; 95.5 versus 64.0) and greatest relative difference in brain (>700%, 28.5 versus 4.0).

CONCLUSION

In the first year of the pandemic, patients who tested positive for COVID-19 between oncologic diagnosis and initial management experienced significant delays in initiation of cancer-directed therapy compared to those who did not test positive for COVID-19, with median increase in TTFT of 21 days. Additional follow-up is needed to evaluate the clinical impact of these delays, as well as change in patterns of care in later years of the pandemic.

Clinician Communication With Patients About Cancer Misinformation: A Qualitative Study

PURPOSE

Clinicians regularly face conversations about information that patients have found online. Given the prevalence of misinformation, these conversations can include cancer-related misinformation, which is often harmful. Clinicians are in a key position as trusted sources of information to educate patients. However, there is no research on clinician-patient conversations about cancer-related misinformation. As a first step, the objective of this study was to describe how cancer clinicians report communicating with patients about online cancer misinformation.

METHODS

We used convenience and snowball sampling to contact 59 cancer clinicians by e-mail. Contacted clinicians predominately worked at academic centers across the United States. Clinicians who agreed participated in semistructured interviews about communication in health care. For this study, we focused specifically on clinicians' experiences discussing online cancer-related misinformation with patients. We conducted a thematic analysis using a constant comparative approach to identify how clinicians address misinformation during clinical visits.

RESULTS

Twenty-one cancer clinicians participated in the study. Nineteen were physicians, one was a physician assistant, and one was a nurse practitioner. The majority (62%) were female. We identified four themes that describe how cancer clinicians address misinformation: (1) work to understand the misinformation; (2) correct misinformation through education; (3) advise about future online searches, and (4) preserve the clinician-patient relationship.

CONCLUSION

Our study identified four strategies that clinicians use to address online cancer-related misinformation with their patients. These findings provide a foundation for future research, allowing us to test these strategies in larger samples to examine their effectiveness.

Using ChatGPT to evaluate cancer myths and misconceptions: artificial intelligence and cancer information

Data about the quality of cancer information that chatbots and other artificial intelligence systems provide are limited. Here, we evaluate the accuracy of cancer information on ChatGPT compared with the National Cancer Institute's (NCI's) answers by using the questions on the "Common Cancer Myths and Misconceptions" web page. The NCI's answers and ChatGPT answers to each question were blinded, and then evaluated for accuracy (accurate: yes vs no). Ratings were evaluated independently for each question, and then compared between the blinded NCI and ChatGPT answers. Additionally, word count and Flesch-Kincaid readability grade level for each individual response were evaluated. Following expert review, the percentage of overall agreement for accuracy was 100% for NCI answers and 96.9% for ChatGPT outputs for questions 1 through 13 (ĸ = ‒0.03, standard error = 0.08). There were few noticeable differences in the number of words or the readability of the answers from NCI or ChatGPT. Overall, the results suggest that ChatGPT provides accurate information about common cancer myths and misconceptions.

Initial results of a phase 2 pilot study of radium-223 and radiotherapy in untreated hormone-naïve men with oligometastatic prostate cancer to bone

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Background: We hypothesized that treatment with Radium-223 (Ra223) and to ≤5 sites of bony metastases (mets) could safely delay the time to start androgen deprivation therapy (ADT) and maintain quality of life (QoL). Methods: 20 men previously treated with surgery, radiation, or both for M0 PCa later developed ≤5 bone-only mets were eligible for this prospective trial. Inclusion: testosterone ≥ 100 ng/dL and mets on conventional bone scan, validated by a CT, MRI, or PET/CT. Exclusion: LHRH therapies after initial treatment, or N1 disease at diagnosis of bone mets. Therapy was 6 cycles of Ra223 and SBRT (30 Gy in 5 fractions between cycles 1-2). Bone scan was performed at baseline and q3 months. PSA was evaluated monthly during the Ra223 course, and q3 months after. Therapeutic effectiveness was defined as ≥20% of patients meeting the primary endpoint of freedom from ADT (FFAdt) use at 15 months. Discontinuation of study therapy occurred if: PSA rise > 10% if baseline PSA >20ng/ml, PSA>20 if baseline PSA <20 ng/ml, radiographic progression or a skeletal-related event (SRE). All endpoints were timed from the Cycle 1 radium date. Patients were followed for 2 years. Clinically significant changes in patient-reported outcome (PRO) measures were defined as >1/2 standard deviation from the mean baseline value and were censored after the time of ADT use. Continuous and categorical covariates were compared using the Wilcoxon rank sum and Pearson’s Chi2 tests, respectively, and univariate Cox regression. Statistical significance was considered at P<0.05. Results: The median number of Ra223 cycles was 6. 6 patients had <6 cycles (range 2-5) due to progression. FFAdt at 15 and 24 Months was 49.5% and 38.5%, respectively (p<0.001). The median time to ADT was 14.8 months. There were no significant changes from baseline in any PRO QoL domain (physical functioning, anxiety, depression, fatigue, satisfaction with participation in social roles, sleep disturbance, and pain interference). There were 2 patients with Grade 3 SREs (bone fracture, pain). Grade 2+ events attributed as possible or likely to Ra-223 were seen in 4 patients (bone pain, fatigue, fracture, decreased WBC count, and other). Grade 2+ events attributed as possible or likely to EBRT were seen in 2 patients and included fatigue and other pain. were noted for age, baseline PSA, days from primary treatment, NCCN risk group, TNM stage, ISUP grade group, BMI, or # of lesions in those who met or failed the primary endpoint (all p>0.05). Conclusions: First-line use of Ra223 and SBRT to oligomets in hormone-naïve men in this prospective pilot study resulted in a significant delay in ADT use compared to historical control, is well tolerated, and maintains QoL. Clinical trial information: NCT03304418 .

Plasma proteome landscape and impact of the circulatory proteome on clinical outcomes in metastatic prostate cancer

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Background: We performed plasma-based high-plex proteomic profiling for identifying classifiers of clinical outcomes in metastatic prostate cancer (PC). Olink Explore NGS-based proteome profiling platform was used for high-precision analysis of 736 cancer associated plasma proteins in plasma samples from non-metastatic stage prostate cancer (PC), metastatic hormone-sensitive PC (mHSPC) and metastatic castrate resistant PC (mCRPC) states. Methods: Plasma was collected prospectively in a cohort of 108 PC patients (24 with non-metastatic PC; 28 mHSPC; 56 mCRPC of which 37 patients were collected before starting any mCRPC treatments). Proteomic data were generated with Proximity Extension Assay (PEA) on the Olink platform from 100 µL plasma per sample. Levels of 736 cancer-associated protein assays were denoted as normalized protein expression (NPX) units through a QC and normalization process developed and provided by Olink. Data generation of NPX consists of normalization to the extension control, log2 -transformation, and level adjustment using the plate control (plasma sample). Temporal trends of differentially expressed assays in non-metastatic PC, mHSPC and mCRPC states were identified using linear mixed effects model (FDR with Benjamini-Hochberg (BH) adjustment; q-value<0.05, R version 4.1.2.). Clinical outcomes included in mCRPC state overall survival (calculated as time from turning mCRPC to death) and in mHSPC early failure of ADT-based therapies defined as progression within 12.5 months. Cox proportional hazard regression was performed for proteins associated with mHSPC and mCRPC states and clinical endpoint of interest. Results: After BH adjustments, 105 protein assays were differentially expressed across non-metastatic, mHSPC and mCRPC states of which 73 assays differed between non-metastatic and metastatic states (q<0.05). 83/105 assays differed between mHSPC and mCRPC states (q<0.05). Of the 83 plasma proteins, 77 were over-expressed in mCRPC. 19/37 mCRPC patients who had collections performed before mCRPC treatments had died. The median time to death was 29 months (Range: 1.9-119 mths). After adjustment for serum Alkaline phosphatase (ALP) levels in these 37 mCRPC patients 32/77 were significantly associated with overall survival. After performing an enrichment analysis the oxidative phosphorylation pathway with specific proteins assays (IMMT, COX5B and FXN, p = 5.1e-4, FDR = 2.55 e-2) were significantly overexpressed in patients with poor survival. Conclusions: A global plasma proteomic profiling of cancer related proteins revealed significant differences in expression in different states of cancer progression. Overexpressed proteins related to oxidative phosphorylation pathway in mCRPC in specific are associated with poor survival.

Identifying Cancer Treatment Misinformation and Strategies to Mitigate Its Effects With Improved Radiation Oncologist-Patient Communication

Accurate information about cancer treatment is critical for individuals to make informed decisions about their health. Unfortunately, the rise of the Internet and social media combined with patients' desire for autonomy as well as the increased availability and marketing of unproven or disproven therapies has made it easy for misinformation about cancer to spread. This can have grave consequences for patients, as individuals who rely on misinformation may make decisions that put their health at risk, including choosing to forego effective treatment in favor of unproven or disproven therapies. To address these serious issues, it is important to understand what constitutes cancer treatment misinformation and the available mitigation strategies. This knowledge can inform efforts to counteract the spread of cancer treatment misinformation and promote accurate information about cancer.

Evaluating patterns of care for early-stage low-grade follicular lymphoma in the rituximab era

Radiotherapy (RT) utilization for early-stage, low-grade follicular lymphoma (FL) is low despite treatment guideline recommendations. We compare treatment trends for early-stage FL in the era of involved-site RT and rituximab. We identified 11,645 patients in the National Cancer Database (NCDB) with stage I-II, grade 1-2 nodal or extranodal FL diagnosed 2011-2017, with median follow-up of 44 months. From 2011 to 2017, RT utilization rates decreased from 33.4% to 22.4%, observation decreased from 65.3% to 49.7%, chemoimmunotherapy increased from 0.5% to 15.0%, immuno-monotherapy increased from 0.6% to 10.2%, and RT + systemic therapy increased from 0.6% to 2.5%. RT utilization remains low in the involved-site RT and rituximab era.

International medical tourism of US cancer patients for alternative cancer treatments: Financial, demographic, and clinical profiles of online crowdfunding campaigns

BACKGROUND

Previous research has found that individuals may travel outside their home countries in pursuit of alternative cancer therapies (ACT). The goal of this study is to compare individuals in the United States who propose plans for travel abroad for ACT, compared with individuals who seek ACT domestically.

METHODS

Clinical and treatment data were extracted from campaign descriptions of 615 GoFundMe® campaigns fundraising for individuals in the United States seeking ACT between 2011 and 2019. We examined treatment modalities, treatment location, fundraising metrics, and online engagement within campaign profiles. Clinical and demographic differences between those who proposed international travel and those who sought ACT domestically were examined using two-sided Fisher's exact tests. Differences in financial and social engagement data were examined using two-sided Mann-Whitney tests.

RESULTS

Of the total 615 campaigns, 237 (38.5%) mentioned plans to travel internationally for ACT, with the majority (81.9%) pursuing travel to Mexico. Campaigns that proposed international treatment requested more money ($35,000 vs. $22,650, p < 0.001), raised more money ($7833 vs. $5035, p < 0.001), had more donors (57 vs. 45, p = 0.02), and were shared more times (377 vs. 290.5, p = 0.008) compared to campaigns that did not. The median financial shortfall was greater for campaigns pursuing treatments internationally (-$22,640 vs. -$13,436, p < 0.003).

CONCLUSIONS

Campaigns proposing international travel for ACT requested and received more money, were shared more online, and had more donors. However, there was significantly more unmet financial need among this group, highlighting potential financial toxicity on patients and families.

Patterns of care and outcomes of early stage I-II Hodgkin lymphoma treated with or without radiation therapy

Omission of radiotherapy in the upfront management of early-stage classic Hodgkin lymphoma (cHL) has become more common with time. We report patterns of care and outcomes of stage I-II cHL treated with chemotherapy (CT) only versus CT and radiotherapy (combined modality therapy, CMT). From the National Cancer Database, we identified 28,327 early-stage cHL patients treated with CT (n = 15,798) or CMT (n = 12,529) from 2004 to 2018. CMT utilization declined over the period from 58% to 34%. With median follow-up of 6.2 years, the 5- and 10-year overall survival for CT versus CMT was 93.3% versus 96.9% (p < 0.001) and 88.7% versus 93.5% (p < 0.001), respectively. On multivariable analysis, uninsured (OR 0.75, p < 0.001) and Black patients (OR 0.86, p = 0.02) were less likely to receive CMT, and treatment with CT was predictive of death (OR 2.0, p < 0.001). This report highlights real-world outcomes in early-stage cHL, with worse survival with CT and notable disparities in CMT utilization.

Cancer Misinformation and Harmful Information on Facebook and Other Social Media: A Brief Report

There are few data on the quality of cancer treatment information available on social media. Here, we quantify the accuracy of cancer treatment information on social media and its potential for harm. Two cancer experts reviewed 50 of the most popular social media articles on each of the 4 most common cancers. The proportion of misinformation and potential for harm were reported for all 200 articles and their association with the number of social media engagements using a 2-sample Wilcoxon rank-sum test. All statistical tests were 2-sided. Of 200 total articles, 32.5% (n = 65) contained misinformation and 30.5% (n = 61) contained harmful information. Among articles containing misinformation, 76.9% (50 of 65) contained harmful information. The median number of engagements for articles with misinformation was greater than factual articles (median [interquartile range] = 2300 [1200-4700] vs 1600 [819-4700], P = .05). The median number of engagements for articles with harmful information was statistically significantly greater than safe articles (median [interquartile range] = 2300 [1400-4700] vs 1500 [810-4700], P = .007).

Complementary and alternative medicine exposure in oncology (CAMEO) study: A multi-institutional cross-sectional analysis of patients receiving cancer treatment

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Background: Compared to standard of care treatments, complementary and alternative medicine (CAM) use has been associated with decreased survival in cancer patients. CAM includes a broad range of treatments including vitamins/minerals, herbs/supplements, special diets, and mind/body interventions. An improved understanding of contemporary prevalence, predictors and intended goals of CAM use is needed to improve the cancer patient experience and guide shared decision-making regarding risks and benefits of their use. Methods: A cross-sectional survey of prospectively enrolled adult cancer patients treated at a large regional non-profit cancer center and an NCI-Designated Comprehensive Cancer Center between 2020 and 2021 was collected. Patients receiving cancer treatment were selected for analysis and grouped based on reported CAM use. Differences between CAM users and nonusers were assessed by chi-squared for categorical and two-sample t-test for continuous variables. Predictors of CAM use were identified with univariable and multivariable logistic regression. Results: Of 749 respondents, 83.31% had heard of or been recommended a CAM. Rates of CAM use during cancer treatment were highest for vitamins/minerals (56%), mind/body (52%), herbs/supplements (38%), special diets (30%), and other (12%). In the most common primary cancers, overall rates of CAM use were high (Breast: 84%, prostate: 66%, lung: 79%). Most patients (91%) use CAM in addition to conventional treatments. The intended goal of CAM therapy was most often management of symptoms (42%), treatment of cancer (30%), and mental health (15%). CAM users were younger than non-users (median age 62 years [y] vs 65y, p = 0.03). Females had higher rates of CAM use compared to males (86% vs. 78%, p < 0.01). Patients with incurable cancer had higher rates of CAM use than those with curable cancer (82% vs. 72%, p < 0.01). Predictors of CAM use on multivariable model include female gender (OR 2.5, p < 0.01) and incurable cancer (OR 2.5, p < 0.01). During cancer treatment, patients using CAM used multiple therapies and therapy types, including an average of 3.3 vitamins/minerals, 3.1 herbs/supplements, 2.5 mind/body exercises, and 1.6 special diets. Conclusions: CAM use is common among cancer patients receiving radiation, chemotherapy, and or surgery. Many patients are taking multiple CAM therapies during treatment with one third of patients using CAM with the intended goal of treating their cancer. This data provides details about and predictors of CAM use and provides information to guide patient-physician discussions.

Shifting perceptions of alternative therapies in cancer patients during the COVID-19 pandemic: Results from the Complementary and Alternative Medicine Exposure in Oncology (CAMEO) Study

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Background: Complementary and alternative medicine (CAM) use has been associated with worse survival outcomes in cancer patients compared to standard of care therapies. CAM has received a significant increase in public awareness and interest in the COVID-19 pandemic era. We sought to understand how the COVID-19 pandemic affected CAM use and perceptions in cancer patients. Methods: Data was collected from adult cancer patients prospectively enrolled on a cross-sectional survey conducted at an NCI-designated cancer center and a comprehensive cancer center between 2020 and 2021. The survey included questions assessing changes in patient attitude towards CAM and likelihood of using CAM, both relative to prior to COVID-19. Analyzed CAM users included those taking vitamin, mineral and herbal supplements, alternative medicines and special diets, and excluded mind-body practices as the focus of this analysis was on enteral and parenteral CAM therapies. Differences in the impact of COVID-19 on CAM use beliefs and practices between CAM users and non-users were analyzed with χ2 and two-sample t-tests. Results: Out of 749 respondents, 578 (77%) used any CAM and 470 (63%) used enteral or parenteral CAM. Results shown in table. Compared to prior to COVID-19, CAM users were more likely to view CAM more favorably (12% vs 5%, p < 0.01), while non-users were more likely to have an unchanged opinion (90% vs 84%, p = 0.03). Females had higher rates of viewing CAM more favorably than males (80% vs 58%, p = 0.04). Patients who viewed CAM more favorably had higher rates of self-reported incurable cancer (36% vs 11%, p = 0.04), declining recommended hormone therapy (22% vs 0%, p < 0.01), and higher trust of social media (19% vs 0%, p = 0.02) and websites (24% vs 0%, p < 0.01). Since the start of COVID-19, CAM users were more likely to report increased likelihood of using CAM (12% vs 6%, p = 0.01). Patients who were more likely to use CAM had higher rates of declining recommended chemotherapy (12% vs 0%, p = 0.02), and higher trust of social media (15% vs 2%, p = 0.01) and websites (28% vs 7%, p < 0.01). Conclusions: During the COVID-19 pandemic, attitudes on CAM use in oncology patients have become increasingly polarizing. Patients with favorable attitudes toward CAM were likely to decline recommended standard of care therapy and more like to use CAM since COVID-19. This data helps characterize shifting attitudes toward CAM and may help guide shared decision-making between physician and patient.[Table: see text]

Comparing pretest video genetic education for prostate cancer patients: Do patients need assistance?

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Background: Expanded germline genetic testing recommendations for individuals with prostate cancer (PCa) have resulted in increased demand for pre-test genetic education. As a result, alternative service delivery models in genetic counseling (GC) have been suggested. Previous research has shown no difference in genetic testing uptake when video genetic education (VGE) is used rather than face-to-face counseling. However, data is limited when evaluating how VGE is delivered to patients. This study aimed to evaluate the impact of pre-test VGE on genetic testing uptake when facilitated by a GC assistant or self-completed by the patient. Methods: PCa patients referred for GC were contacted for pre-test VGE. Patients were randomized to undergo VGE with a GC assistant via Zoom (assistant-led) or perform VGE on their own via email instructions (patient-led). Assistant-led VGE was scheduled via standard of care, and patient-led VGE involved electronic and phone contact. In both arms, pre-test VGE included administrating family history collection via electronic software and viewing of informational genetics video. VGE completion and genetic testing uptake was the primary outcome measured for all participants. Initial pilot data was presented previously. This analysis represents the entire study period outcome. Data analysis used t-test, Fisher’s exact and chi square. Results: From 10/1/2020-12/31/2021, 266 PCa patients were referred. In total, 254 were randomized, with 130 in the assistant-led intervention and 124 randomized to the patient-led arm. Technological limitations, loss to follow up, and procedural withdrawals resulted in 41 (31.5%) patients in the assistant-led arm and 65 (52.4%) in the self-led arm. The primary reason for discontinuing the process was lack of patient response to contact to schedule their genetics visit (n = 109, 35 patient-led, 74 assistant-led). There was significantly more loss to follow up in the assistant-led arm versus the self-led arm (p < 0.001). Of those who completed VGE, the median age was 66 years, with no difference between the two arms (p = 0.66). Participants primary identified as white (n = 96, 91%) and non-Hispanic (n = 100, 94%). There was no difference in uptake of genetic testing (p = 0.09) between patient and assistant led VGE. Conclusions: A randomized intervention suggests no difference in genetic testing uptake when pre-test VGE occurs with an assistant or is patient-led. Analyses of satisfaction, decision conflict, and knowledge are needed to evaluate if patient-led VGE is a suitable alternative to GC. Loss to follow up given standard of care scheduling approaches for assistant-led VGE suggests pre-test VGE may be better delivered during oncology visits. Additional evaluation of the facilitators and barriers, in addition to larger multi-center studies, are required to consider patient-led pre-test VGE as a primary method of pre-testing genetic education.

Ethical Reasoning During a Pandemic: Results of a Five Country European Study

Introduction: There has been no work that identifies the hidden or implicit normative assumptions on which participants base their views during the COVID-19 pandemic, and their reasoning and how they reach moral or ethical judgements. Our analysis focused on participants' moral values, ethical reasoning and normative positions around the transmission of SARS-CoV-2.Methods: We analyzed data from 177 semi-structured interviews across five European countries (Germany, Ireland, Italy, Switzerland and the United Kingdom) conducted in April 2020.Results: Findings are structured in four themes: ethical contention in the context of normative uncertainty; patterns of ethical deliberation when contemplating restrictions and measures to reduce viral transmission; moral judgements regarding "good" and "bad" people; using existing structures of meaning for moral reasoning and ethical judgement.Discussion: Moral tools are an integral part of people's reaction to and experience of a pandemic. 'Moral preparedness' for the next phases of this pandemic and for future pandemics will require an understanding of the moral values and normative concepts citizens use in their own decision-making. Three important elements of this preparedness are: conceptual clarity over what responsibility or respect mean in practice; better understanding of collective mindsets and how to encourage them; and a situated, rather than universalist, approach to the development of normative standards.

Impact of pretest video genetic education in prostate cancer patients: Do patients need us?

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Background: Germline genetic testing criteria for individuals with prostate cancer (PCa) are expanding. Alternative genetic service models are needed to meet increased need for genetic testing. Studies have shown no difference in genetic testing uptake, satisfaction, or knowledge when patients undergo face-to-face genetic counseling compared to pre-test video genetic education (VGE). Data is limited comparing options for how video genetic education is delivered. This study evaluated the impact of pre-test VGE when facilitated by a genetic counseling assistant (assistant-led) or self-completed by the patient (patient-led). Methods: Individuals with PCa referred for genetic counseling received pre-test VGE. Patients were randomized so that this process involved meeting with a genetic counseling assistant or completed at the patient’s convenience via email instructions. Pre-test VGE included family history completion via electronic software and viewing of informational video. VGE completion and genetic testing uptake were measured for all participants. Questionnaires regarding satisfaction, and knowledge were optional for participants after VGE completion. Data was analyzed using t-test and Fisher’s exact. Results: Eighty-one individuals referred for genetic counseling from October 2020-March 2021, and 78 individuals were randomized (1:1) to assistant-led or patient-led VGE, with 39 individuals in each arm. After removing patients for technological limitations, loss to follow up, and procedural withdrawals, there were 18 patients in the assistant-led arm, and 16 patients in the patient-led arm. The primary reason for discontinuing the process was lack of response to phone and electronic contacts to schedule their genetics visit (n = 22). The median age was 64.5 years, with no difference between the two arms (p = 0.698). Participants identified primarily as white/Caucasian (n = 32, 94%). In the assistant-led group, all participants elected to undergo germline genetic testing and 13 (81%) opted for genetic testing in the patient-led group. There was no difference in genetic testing uptake between the two arms (p = 0.094). Nine patients in the patient-led group and eight patients in the assistant-led group completed the questionnaires. There was no difference in satisfaction with their VGE experience (p = 0.815) or knowledge using the KnowGene scale (p = 0.120). Conclusions: Preliminary data suggests there is no difference in genetic testing uptake when pre-test VGE is facilitated by a genetic counseling assistant or self-led by the patient. Given no preliminary differences in satisfaction and knowledge, patient-led pre-test VGE may serve as a viable option prior to germline testing in PCa patients. Additional research is needed with larger sample size. Furthermore, evaluation of the facilitators and barriers of VGE is needed as there was significant drop off in completion of video pre-test VGE.

The Effect of Maximum Tumor Diameter by MRI on Disease Control in Intermediate and High-risk Prostate Cancer Patients Treated With Brachytherapy Boost

BACKGROUND

Larger maximum tumor diameter (MTD) has been associated with worse prostate cancer (PCa) outcomes. However, the impact of MTD in PCa treated with external beam radiotherapy and brachytherapy boost (EBRT+BB) remains unknown.

MATERIALS AND METHODS

Patients with PCa treated with EBRT+BB were identified from an institutional database. Clinical data including MTD, age, androgen deprivation therapy (ADT) use, prostate specific antigen (PSA), International Society of Urologic Pathology (ISUP) group, clinical T-stage, and presence of adverse pathology on imaging were retrospectively collected. Multivariable and univariable cox proportional hazards models for biochemical failure (BF) and distant metastasis (DM) were produced with MTD grouped by receiver operating characteristic (ROC) cut-point. Cumulative hazard functions for BF and DM were compared with log-rank test and stratified by ISUP group.

RESULTS

Of 191 patients treated with EBRT+BB, 113 had MTD measurements available. Larger MTD was associated with increased ADT use and seminal vesicle involvement. ROC optimization identified MTD of 24 mm as the optimal cut-point for both BF and DM. MTD was independently associated with both BF (HR 8.61, P = .048, 95% CI 1.02-72.97) and DM (HR 8.55, P = .05, 95% CI 1.00-73.19). In patients with ISUP group 4 to 5 disease, MTD > 24 mm was independently associated with increased risk of DM (HR 10.13, P = .04, 95% CI 1.13-91.12).

CONCLUSIONS

This is the first study to evaluate MTD in the setting of EBRT+BB. These results demonstrate that MTD is independently associated with BF and metastasis. This suggests a possible role for MTD in risk assessment models and clinical decision-making for men receiving EBRT+BB.

Growth in eligibility criteria content and failure to accrue among National Cancer Institute (NCI)-affiliated clinical trials

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Background: Cancer clinical trial accrual across diverse socioeconomic and demographic groups is a national priority, yet up to 20% of trials fail due to poor accrual. Eligibility criteria content may contribute to poor accrual, but effects are challenging to measure. We sought to evaluate growth of eligibility criteria within NCI-affiliated cancer trials and the impact on trial accrual over the past decade. Methods: We conducted a retrospective study with the Aggregate Analysis of ClinicalTrials.gov (AACT) (abstracted: 02/02/2021). We included NCI-affiliated, interventional Phase II or III trials that initiated between 01/01/2008 and 12/13/2018. We excluded active and recruiting trials that lacked accrual data on the Cancer Trials Support Unit website. Trials whose status was “Withdrawn”, “Terminated”, or “Suspended” due to low accrual, or had less than 50% target accrual after two years active were deemed accrual failures. Eligibility criteria were extracted from inclusion and exclusion criteria and complexity was estimated by the number of unique content words, calculated by removing duplicates and stop words from the word count. Association of unique word count with accrual failure was evaluated by univariable and multivariable logistic regressions, adjusting for other predictors of low accrual identified in earlier research. Results: Of 1197 trials included, 231 (19.3%) failed due to low accrual. Eligibility criteria increased in length from a median of 214 (IQR [23, 282]) unique content words in 2008 to 417 (IQR [289, 514]) in 2018. The rate of trial accrual failure increased with unique word count decile from 11.8% in the first decile (12 to 112 words) to 29.4% in the tenth decile (445 to 750 words) (P = 0.004). On multivariable analysis, unique word count remained independently associated with low accrual (OR: 1.07 per decile, 95%CI [1.01-1.13], P = 0.02), as did Phase III and metastatic disease settings (Table). Conclusions: Eligibility criteria content has increased dramatically in the last decade in NCI-affiliated trials. Increasing eligibility criteria content associates strongly with accrual failure, even after adjusting for multiple known predictors of accrual. These findings underscore the need for efforts to simplify eligibility criteria to improve trial accrual. Further investigation is ongoing to determine specific criteria qualities that portend accrual failure.[Table: see text]

Temporal Trends and Predictors in Diagnosing Pathologic Node-Positive Prostate Cancer in Clinically Node-Negative Patients

INTRODUCTION

Managing pathologically node positive (pN+) prostate cancer (PCa) is controversial. We describe temporal patterns and predictors of pN+ PCa in men with initially surgically managed clinically node negative (cN-) PCa.

MATERIALS AND METHODS

This observational retrospective analysis of nonmetastatic, cN- PCa uses the National Cancer Database. Multivariable logistic regression was used to identify covariates associated with pN+ disease. Cox proportional hazards modeling and Kaplan-Meier analysis were used to evaluate survival patients undergoing radical prostatectomy with or without pelvic lymph node dissection (PLND).

RESULTS

The rates of radical prostatectomy in men with grade group (GG) 4 and GG5 increased from 47.6% to 53.1% and from 42.5% to 49.5%, respectively. The annual rate increased from 2.02% in 2010 to 5.12% in 2017 (P < .001). The annual rates of PLND increased from 54.3% to 71.7%. The most significant predictor of pN+ PCa was ISUP GG4 (odds ratio [OR] 12.5, P< .001) and GG 5 (OR 26.2, P < .001). Rates of pN+ identification increased from 5.5% to 9.4% in men with GG4 and from 13.4% to 19.5% in men with GG5 (P< .001). In GG4 and GG5, patients undergoing PLND had superior survival to those managed without PLND (P < .01).

CONCLUSION

Among patients with cN- PCa, the diagnosis of pN+ PCa has become more common over time. GG4 and GG5 are the strongest independent predictors of pN+ disease. Because incidental pN+ results in upstaging these data are useful for informing discussions before radical prostatectomy.

Temporal trends and predictors in diagnosing pathologic node-positive prostate cancer in clinically node-negative patients

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Background: The management of men with pathologically node positive (pN+) prostate cancer (PCa) is controversial. Here, we describe the temporal patterns and predictors of incidental pN+ PCa men with clinically node negative (cN0) PCa. Methods: We performed a retrospective analysis of men with nonmetastatic, cN0, PCa from the National Cancer Database from 2010 to 2017. Clinical factors included in analysis were pretreatment PSA, pre-surgical International Society of Urological Pathology (ISUP) grade group (GG), clinical T-stage, margin status, and number of nodes sampled. Patient demographic factors included in analysis were age, comorbidity index, race, insurance status, and treatment facility type. We performed univariable and multivariable logistic regression to evaluate temporal trends in the rates of cN0,pN+ prostate cancer diagnosed over time. Two-level hierarchical logistic regression was used to identify covariates associated with pN+ disease. Patients were clustered within treatment facilities to account for individual facility practice patterns. Results: We identified 304,234 men with cN0 PCa who underwent radical prostatectomy (RP) between 2010 and 2017. Within this group 10,919 (3.59%) were found to have pN+ disease. During this period, the annual rate of pN+ PCa increased from 2.02% (n=822) in 2010 to 5.12% (n=2,072) in 2017 (p<0.001). On multivariable logistic regression, ISUP GG was most strongly associated with detection of pN+ PCa. Compared to ISUP GG1, GG2 (OR 3.5, p <0.001), GG3 (OR 8.8, p <0.001), GG4 (OR 12.6, p <0.001) and GG 5 (OR 26.5, p <0.001 ) were all significantly associated with pN+ PCa. Over the study period, the rates of pN+ identification increased from 5.5% to 9.4% in men with GG4, and from 13.4% to 19.5% in men with GG5 (p <0.001). Between 2010 and 2017, the rates of RP in GG4 and GG5 similarly increased by 12% and 16%, respectively (p <0.001). Other significant covariates are depicted in Table. 22% of the total variance was explained by inter-facility variation. Conclusions: The proportion of men with cN0 found to have pN+ PCa is increasing over time, with pN+ incidentally found in nearly 1 in 10 men with GG4 and 1 in 5 men with GG5 PCa. GG4 and GG5 are the strongest independent predictors of pN+ disease, while controlling for clinical and demographic factors. As incidental pN+ results in upstaging, often requiring adjuvant treatment with radiation and systemic therapies, these data are useful for informing discussions prior to RP. [Table: see text]

The effect of maximum tumor diameter on disease control in intermediate and high-risk prostate cancer patients treated with brachytherapy boost

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Background: Larger maximum tumor diameter (MTD) has been associated with worse prostate cancer outcomes for those undergoing surgery as well as salvage radiation. MTD is also an important consideration for patients weighing active surveillance. However, the impact of MTD in intermediate and high-risk prostate cancer treated with external beam radiotherapy (EBRT) and brachytherapy boost is unknown. We set out to evaluate MTD of the dominant nodule on MRI as a prognostic factor in patients treated with EBRT and brachytherapy boost for localized prostate cancer. Methods: Patients with prostate cancer treated with EBRT and brachytherapy boost were identified from an institutional database. In patients with a pretreatment MRI, data on MTD were retrospectively collected. Clinical data including age, ADT use, pretreatment PSA, International Society of Urologic Pathology (ISUP) group, clinical T-stage, and presence of adverse pathology on imaging (either seminal vesicle invasion or extraprostatic extension) were also collected. Multivariable and univariable cox proportional hazards models for biochemical failure (BF) and distant metastasis (DM) were produced in patients with MTD grouped by receiver operating characteristic (ROC) cutpoint. Cumulative hazard functions for BF and DM were compared with log-rank test and stratified by ISUP group. Results: Of 191 patients treated with EBRT and brachytherapy boost, 113 had pretreatment MRI and available MTD measurement. Median follow up was 40 months (interquartile range 23-66 months) and median MTD was 17 mm (interquartile range 13-22mm). Increasing MTD was associated with higher T stage and increased ADT use. ROC cutpoint optimization identified MTD of 24mm to be the optimal cut-point for both BF and DM. On univariate log-rank analysis, patients with MTD > 24mm had higher 5-year BF (31% vs 4%, p = 0.004) and DM (21% vs 4%, p = 0.002) than those with MTD≤24. Stepwise multivariable cox model for BF (P = 0.130, HR 1.08, 95% CI 0.98-1.21) and DM (P = 0.115, HR 1.09, 95% CI 0.98-1.23), MTD did not demonstrate statistical significance when controlling for clinical t-stage, adverse pathologic features on imaging, ISUP group, and ADT use. However, in patients with ISUP group 4-5 disease, MTD > 24 was independently associated with increased risk of DM (P = 0.032, HR 1.18, 95% CI 1.01-1.37). Conclusions: This is the first study to evaluate MTD on MRI as a prognostic factor in the setting of brachytherapy boost. These results demonstrate that for patients treated with EBRT and brachytherapy boost, MTD is independently associated with risk for metastasis in patients with ISUP grade 4 and 5 disease. Although these results require further validation, this suggests a possible role for MTD as a factor in risk assessment models and clinical decision-making.

Patterns of care and treatment outcomes in locoregional squamous cell carcinoma of the prostate

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Background: Primary pure prostate squamous cell carcinoma (PSCC) is a rare, aggressive disease accounting for less than 0.5-1% of prostate cancer diagnoses. PSCC is a distinct entity from adenocarcinoma with historically poor outcomes, often presenting in younger patients with lower urinary tract symptoms and normal PSA. There are currently no established treatment guidelines. Case reports are limited but describe multiple treatment approaches including various combinations of surgery, platinum and non-platinum-based chemotherapy, radiotherapy and androgen deprivation therapy, with selected reports showing longer survival times with a combined modality approach. Methods: Seeking to identify practice patterns and treatment outcomes, we performed a retrospective analysis of the United States National Cancer Database to identify 66 males with locoregional, nonmetastatic primary pure squamous cell carcinoma of the prostate and treated with surgery, chemotherapy, and/or radiotherapy between 2004 and 2015. Clinical factors in analysis included pretreatment PSA, clinical T-stage, histology, treatment modality and demographic factors including age, comorbidity index, race, insurance status and treatment facility type. Patients were stratified into treatment groups consisting of local therapy alone (n = 40, 60%), local therapy and chemotherapy (n = 13, 20%), chemotherapy alone (n = 7, 11%), and observation (n = 6, 9%). Survival analysis was estimated using the Kaplan-Meier method and analyzed with log-rank testing. A Cox proportional hazards model was used to evaluate the association between patient characteristics and survival. Univariable and multivariable logistic regression was performed to identify covariates associated with receipt of each treatment modality. Results: With an overall median follow-up of 21.9 months, median survival was 19.7 months for patients treated with local therapy alone, 10.9 months with chemotherapy alone, and 36.5 months with combined local therapy and chemotherapy. Overall survival was not statistically significant between treatment groups. Statistically significant predictors of death included age (HR 1.1, 95% CI [1.03-1.17]) and clinical stage ≥T3a (HR 4.05, 95% CI [1.35-12.2]). Statistically significant predictors of receipt of chemotherapy were clinical stage T3a or greater (OR 34.6, 95% CI [2.65-364]) and age (OR 0.91, 95% CI [0.82-99]). Conclusions: This analysis represents the largest reported cohort analysis of locoregional pure PSCC. Unfortunately, due to the rarity of this disease, prospective or randomized trials to determine the optimal treatment strategy are not feasible. Despite limitations in sample size, and in the absence of prospective data, this analysis suggests the addition of chemotherapy to local therapy is a reasonable treatment approach in appropriately selected patients and may result in improved survival.

The implications of treatment delays in adjuvant therapy for cholangiocarcinoma patients

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Background: To understand the factors associated with timing of adjuvant therapy in the management of intrahepatic and extrahepatic cholangiocarcinoma and the impact of delays on overall survival (OS). Methods: Data from the NCDB for patients with pathologically proven non-metastatic adenocarcinoma of the bile ducts from 2004 to 2014 were pooled and screened. Patients were included only if they underwent surgery and adjuvant chemotherapy (CMT) and/or radiotherapy (RT). Patients who underwent neoadjuvant therapy or received CMT or RT with palliative intent were excluded. Pearson’s chi-squared test and multivariate logistic regression analyses were used to assess the distribution of demographic, clinical, and treatment factors. After propensity-score matching with inverse probability of treatment weighting, OS was compared between patients who had initiation of adjuvant therapy past various time points using Kaplan Meier analyses and doubly-robust estimation with multivariate Cox proportional hazards modeling. Results: In total, 7,422 patients in our analysis underwent adjuvant treatment. This represented 43% of the study cohort of 17,123 patients. Of the patients who underwent adjuvant treatment, 3,956 (53%) initiated adjuvant therapy by two months, 6,234 (84%) by 3 months and 6,987 (94%) by four months. High-grade disease, macroscopically positive margins, tumors larger than five centimeters, and unknown LVSI status, were associated with earlier initiation of adjuvant treatment at two months or earlier. Patients who received early adjuvant therapy were also more likely to be treated with a combination of CMT and RT. Factors associated with delay of adjuvant therapy beyond three months post-surgery included Charlson scores of one or greater and Hispanic race. After propensity score weighting, there was no survival difference between groups when comparing initiation of adjuvant therapy before or after two, three or four month time points Conclusions: We identified a number of patient characteristics related to the timing of initiating adjuvant therapy in patients with biliary cancers. There were no significant difference in OS associated with delaying adjuvant therapy beyond two, three or four month time-points. Our findings are relevant in the era of COVID-19 when minimizing patient exposure to health-care settings during a pandemic may need to be considered when deciding on the timing of adjuvant therapy. If a delay is necessary, our results suggest that there is no survival detriment to initiating adjuvant therapy beyond three or four months after surgery for biliary cancers.

Patterns of Care and Treatment Outcomes in Locoregional Squamous Cell Carcinoma of the Prostate

Primary squamous cell carcinoma is a rare, aggressive disease with historically poor outcomes and no established treatment guidelines. Case reports are limited but describe multiple treatment approaches. Seeking to identify practice patterns and treatment outcomes, we used the US National Cancer Data Base to identify 66 males with locoregional primary squamous cell carcinoma of the prostate treated with surgery, chemotherapy, and/or radiotherapy between 2004 and 2015. Patients were stratified into treatment groups consisting of local therapy alone (n = 40; 61%), local therapy and chemotherapy (n = 13; 20%), chemotherapy alone (n = 7; 11%), and observation (n = 6; 9%). Patients with clinical stage T3–T4 disease were significantly more likely to receive combined chemotherapy and local therapy on multivariable analysis. Median survival was 20 mo for patients treated with local therapy alone, 37 mo with local therapy and chemotherapy, and 11 mo with chemotherapy alone. Overall survival was not significantly different between treatment groups. Despite limitations in sample size, these data suggest that addition of chemotherapy to local therapy is a reasonable treatment approach for select patients.

Patient summary

Squamous cell carcinoma of the prostate is an extremely rare disease. Our review of patterns of care using data from the National Cancer Data Base shows inconsistent use of combined local and systemic therapy. The small sample size for this rare disease limits any conclusions regarding survival differences, but the data suggest that a combination approach using chemotherapy in addition to surgery or radiation is a reasonable treatment option for disease confined to the prostate.

Quantifying treatment selection bias effect on survival in comparative effectiveness research: findings from low-risk prostate cancer patients

BACKGROUND

Comparative effectiveness research (CER) using national registries influences cancer clinical trial design, treatment guidelines, and patient management. However, the extent to which treatment selection bias (TSB) affects overall survival (OS) in cancer CER remains poorly defined. We sought to quantify the TSB effect on OS in the setting of low-risk prostate cancer, where 10-year prostate cancer-specific survival (PCSS) approaches 100% regardless of treatment modality.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for patients with low-risk prostate cancer (cT1-T2a, PSA < 10, and Gleason 6) who received radical prostatectomy (RP), brachytherapy (BT), or external beam radiotherapy (EBRT) from 2005 to 2015. The TSB effect was defined as the unadjusted 10-year OS difference between modalities that was not due to differences in PCSS. Propensity score matching was used to estimate the TSB effect on OS due to measured confounders (variables present in the database and associated with OS) and unmeasured confounders.

RESULTS

A total of 50,804 patients were included (8845 RP; 18,252 BT; 23,707 EBRT) with a median follow-up of 7.4 years. The 10-year PCSS for the entire cohort was 99%. The 10-year OS was 92.9% for RP, 83.6% for BT, and 76.9% for EBRT (p < 0.001). OS differences persisted after propensity score matching of RP vs. EBRT (7.4%), RP vs. BT (4.6%), and BT vs. EBRT (3.7%) (all p < 0.001). The TSB effect on 10-year OS was estimated to be 15.0% for RP vs. EBRT (8.6% measured, 6.4% unmeasured), 8.5% for RP vs. BT (4.8% measured, 3.7% unmeasured), and 6.5% for BT vs. EBRT (3.1% measured, 3.4% unmeasured).

CONCLUSIONS

Patients with low-risk prostate cancer selected for RP exhibited large OS differences despite similar PCSS compared to radiotherapy, suggesting OS differences are almost entirely driven by TSB. The quantities of these effects are important to consider when interpreting prostate cancer CER using national registries.

Estimating survival in advanced cancer: a comparison of estimates made by oncologists and patients

PURPOSE

To compare estimates of expected survival time (EST) made by patients with advanced cancer and their oncologists.

METHODS

At enrolment patients recorded their "understanding of how long you may have to live" in best-case, most-likely, and worst-case scenarios. Oncologists estimated survival time for each of their patients as the "median survival of a group of identical patients". We hypothesized that oncologists' estimates of EST would be unbiased (~ 50% longer or shorter than the observed survival time [OST]), imprecise (< 33% within 0.67 to 1.33 times OST), associated with OST, and more accurate than patients' estimates of their own survival.

RESULTS

Twenty-six oncologists estimated EST for 179 patients. The median estimate of EST was 6.0 months, and the median OST was 6.2 months. Oncologists' estimates were unbiased (56% longer than OST), imprecise (27% within 0.67 to 1.33 times OST), and significantly associated with OST (HR 0.88, 95% CI 0.82 to 0.93, p < 0.01). Only 41 patients (23%) provided a numerical estimate of their survival with 107 patients (60%) responding "I don't know". The median estimate by patients for their most-likely scenario was 12 months. Patient estimates of their most-likely scenario were less precise (17% within 0.67 to 1.33 times OST) and more likely to overestimate survival (85% longer than OST) than oncologist estimates.

CONCLUSION

Oncologists' estimates were unbiased and significantly associated with survival. Most patients with advanced cancer did not know their EST or overestimated their survival time compared to their oncologist, highlighting the need for improved prognosis communication training. Trial registration ACTRN1261300128871.

Utilization of online crowdfunding for alternative cancer treatments at home and abroad

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Background: The use of alternative cancer treatments has been associated with decreased survival. However, little is known about the types of individuals who seek out these therapies, the alternative therapies pursued, and the associated costs. We utilized GoFundMe campaigns to characterize the types of patients who sought alternative cancer treatments, the types of therapies pursued, and the associated costs. Methods: We queried GoFundMe ( www.gofundme.com ) for English language campaigns using the term “alternative cancer treatment” using custom code for web scraping on 10/25/2019. We identified 1000 campaigns between 2011-2019, of which, 795 had received donations and were used for analysis. We studied each individual campaign in detail and extracted relevant information. Results: The majority of patients were female (63.5%). The most common cancer types were breast (25.3%), colorectal (10.8%), and lung (5.5%) cancer. Of patients reporting cancer stage, 79.3% had stage IV disease. Of those reporting prior cancer treatment history, 34.8% had never undergone traditional cancer treatment; 42.1%, 46.8%, and 26.6% had undergone prior surgery, chemotherapy, and radiotherapy, respectively. The most common proposed alternative treatments were vitamins and minerals (23.4%), herbs and botanicals (16.1%), special diets (13.0%), supplements (10.8%), heat or light therapy (7.8%), IV infusions (7.8%), homeopathic/naturopathic therapies (7.2%), and hyperbaric oxygen therapy (5.9%). Among all campaigns, a total of $36,394,110 was requested and a total of $8,601,759 (23.9%) was raised. The median campaign fundraising goal was $25900 (US dollars; Interquartile range [IQR] $1000 – $50000); the median amount donated was $5805 (IQR $2595 – $12580). These costs include travel as 629 (79.1%) campaigns were for patients residing in the USA, 70 (8.8%) in Europe, 62 (7.8%) in Canada, and 34 (4.3%) in other regions, from which, 54.3% of patients stated that they planned to travel internationally—most commonly to Mexico—for their alternative cancer treatments. Conclusions: Millions of dollars have been requested and raised between 2011 and 2019 for alternative cancer treatments. The majority of patients sought treatment at alternative clinics internationally, were females, had stage IV disease and primary tumors of the breast, colon/rectum or lung, who had previously undergone traditional cancer therapies, and highlight a group of patients where improved communication/education between providers and patients appears to be needed.

Changes in Length and Complexity of Clinical Practice Guidelines in Oncology, 1996-2019

This cross-sectional study calculates the increase in clinical cancer knowledge represented in the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines from 1996 to 2019.

Abstract P4-14-03: Stage-specific survival of breast cancer patients receiving alternative medicine for treatment of cancer

Background: We previously reported on the decreased survival in cancer patients associated with alternative medicine (AM). There is limited information on incidence and stage-specific survival outcomes of breast cancer patients who receive AM compared to those who receive conventional cancer treatment (CCT). Methods: Patients diagnosed with breast cancer in 2004-2016 were identified using the National Cancer Database. Patients were excluded if they had multiple malignant primaries, had radiation to a site other than breast, had unknown treatment status, received palliative care, or had missing death, estrogen receptor (ER), progesterone receptor (PR), and/or clinical stage information. Those who received an unproven cancer treatment and did not receive any CCT, defined as surgery, radiotherapy, chemotherapy, and/or hormone therapy, were classified within the AM group. Annual cumulative incidence of AM was assessed and differences by year were analyzed by the Cochran-Armitage test. Treatment selection was evaluated by the chi-square test, t-test, and logistic regression. Following 2:1 matching on age, clinical group stage, Charlson-Deyo comorbidity score (CDCS), insurance type, race, and year of diagnosis, overall and stage-specific survival were analyzed using the Kaplan-Meier method, log-rank test, and Cox proportional hazards regression for early stage (clinical stages I and II), locally advanced stage (clinical stage III), and metastatic disease (clinical stage IV).Variables with a p-value of ≤ 0.1 on univariate analyses were selected for entry into multivariable Cox proportional hazards survival modeling. Results: We identified 139 patients with breast cancer who received AM. The annual cumulative incidence of AM varied widely by year with increasing use from 10.8/100,000 in 2012 to 20.5/100,000 in 2015. Use of AM from 2004 to 2015 did not significantly increase. On multivariable analysis, when controlling for demographic and clinical factors, those residing in a non-metropolitan county compared to a metropolitan country (Odds Ratio [OR] = .42, 95% Confidence Interval [CI]  = .17 to .99) and those with a CDCS of 1 compared to 0 (OR = .33, 95% CI = .12 to .91) were less likely to receive AM; those receiving care in a Pacific location compared to a Northeast location (OR = 5.57, 95% CI = 2.61 to 11.88) and those with a clinical stage of 4 compared to 1 (OR = 6.53, 95% CI = 3.30 to 12.94) were more likely to receive AM. Following matching, there were no significant differences between matched characteristics (all p&gt;0.9). On matched univariate survival analysis, AM was associated with worse 5-year survival compared to CCT in the overall group (54% vs 82%, p&lt;0.001; Hazard Ratio [HR]: 2.97, 95% CI 2.01-4.38), as well as in patients with stage I or II (67% vs 91%, p&lt;0.001; HR: 3.88, 95% CI 2.15-6.98), stage III (50% vs 83%, p=0.002; HR: 3.99, 95% CI 1.55-10.30), and stage IV (0% vs 34%, p&lt;0.001; HR: 3.21, 95% CI 1.56-6.59) disease.When controlling for factors associated with survival on univariate analysis, AM remained independently associated with greater risk of death in the overall group (HR: 4.03, 95% CI 2.64-6.15), as well as in patients with stage I or II (HR: 4.03, 95% CI 2.23-7.30), stage III (HR: 5.23, 95% CI 1.83-14.93), and stage IV (HR: 3.27, 95% CI 1.04-10.30) disease. Conclusions: Compared to CCT, AM utilization is rare and is associated with greater risk of death in all breast cancer stages. These results may provide patients and providers with data to assist in informed decision-making and provide novel insights into the contemporary natural history of breast cancer.

Citation Format: Huaqi Li, James B Yu, Cary P Gross, Henry S Park, Skyler B Johnson. Stage-specific survival of breast cancer patients receiving alternative medicine for treatment of cancer [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 P4-14-03.

Multi-institutional retrospective review of stereotactic radiosurgery for brain metastasis in patients with small cell lung cancer without prior brain-directed radiotherapy

Introduction: Patients with small cell lung cancer (SCLC) brain metastasis (BM) typically receive whole brain radiotherapy (WBRT) as data regarding upfront radiosurgery (SRS) in this setting are sparse. Methods: Patients receiving SRS for SCLC BM without prior brain radiation were identified at three U.S. institutions. Overall survival (OS), freedom from intracranial progression (FFIP), freedom from WBRT (FFWBRT), and freedom from neurologic death (FFND) were determined from time of SRS. Results: Thirty-three patients were included with a median of 2 BM (IQR 1-6). Median OS and FFIP were 6.7 and 5.8 months, respectively. Median FFIP for patients with ≤2 versus >2 BM was 7.1 versus 3.6 months, p=0.0303. Eight patients received salvage WBRT and the 6-month FFWBRT and FFND were 87.8%. and 90.1%, respectively. Conclusions: Most SCLC patients with BM who received upfront SRS avoided WBRT and neurologic death, suggesting that SRS may be an option in select patients.

Complementary Medicine, Refusal of Conventional Cancer Therapy, and Survival Among Patients With Curable Cancers

Importance

There is limited information on the association among complementary medicine (CM), adherence to conventional cancer treatment (CCT), and overall survival of patients with cancer who receive CM compared with those who do not receive CM.

Objectives

To compare overall survival between patients with cancer receiving CCT with or without CM and to compare adherence to treatment and characteristics of patients receiving CCT with or without CM.

Design, Setting, and Participants

This retrospective observational study used data from the National Cancer Database on 1 901 815 patients from 1500 Commission on Cancer-accredited centers across the United States who were diagnosed with nonmetastatic breast, prostate, lung, or colorectal cancer between January 1, 2004, and December 31, 2013. Patients were matched on age, clinical group stage, Charlson-Deyo comorbidity score, insurance type, race/ethnicity, year of diagnosis, and cancer type. Statistical analysis was conducted from November 8, 2017, to April 9, 2018.

Exposures

Use of CM was defined as "Other-Unproven: Cancer treatments administered by nonmedical personnel" in addition to at least 1 CCT modality, defined as surgery, radiotherapy, chemotherapy, and/or hormone therapy.

Main Outcomes and Measures

Overall survival, adherence to treatment, and patient characteristics.

Results

The entire cohort comprised 1 901 815 patients with cancer (258 patients in the CM group and 1 901 557 patients in the control group). In the main analyses following matching, 258 patients (199 women and 59 men; mean age, 56 years [interquartile range, 48-64 years]) were in the CM group, and 1032 patients (798 women and 234 men; mean age, 56 years [interquartile range, 48-64 years]) were in the control group. Patients who chose CM did not have a longer delay to initiation of CCT but had higher refusal rates of surgery (7.0% [18 of 258] vs 0.1% [1 of 1031]; P < .001), chemotherapy (34.1% [88 of 258] vs 3.2% [33 of 1032]; P < .001), radiotherapy (53.0% [106 of 200] vs 2.3% [16 of 711]; P < .001), and hormone therapy (33.7% [87 of 258] vs 2.8% [29 of 1032]; P < .001). Use of CM was associated with poorer 5-year overall survival compared with no CM (82.2% [95% CI, 76.0%-87.0%] vs 86.6% [95% CI, 84.0%-88.9%]; P = .001) and was independently associated with greater risk of death (hazard ratio, 2.08; 95% CI, 1.50-2.90) in a multivariate model that did not include treatment delay or refusal. However, there was no significant association between CM and survival once treatment delay or refusal was included in the model (hazard ratio, 1.39; 95% CI, 0.83-2.33).

Conclusions and Relevance

In this study, patients who received CM were more likely to refuse additional CCT, and had a higher risk of death. The results suggest that mortality risk associated with CM was mediated by the refusal of CCT.

Prophylactic Cranial Irradiation Versus Surveillance: Physician Bias and Patient-centered Decision-making

An original work in this month's issue of Clinical Lung Cancer highlights the role of physician bias in the decision to recommend prophylactic cranial irradiation (PCI) to patients with small-cell lung cancer, and presents a patient decision aid to facilitate discussion. After decades of clinical trials, we've learned that PCI can significantly decrease the risk of brain metastases and possibly improve survival. However, PCI is also associated with negative impacts on cognition and quality of life. At present, there is no consensus on how to balance these risks and benefits. Understanding and exploring these issues in a structured fashion offers an opportunity to return decision-making to patients, incorporating their values and priorities.

Spinal Growth Patterns After Craniospinal Irradiation in Children With Medulloblastoma

PURPOSE

This study aimed to evaluate the impact on spine growth in children with medulloblastoma using either photon or electron craniospinal irradiation (CSI).

METHODS AND MATERIALS

This was a single institution retrospective review of children who were treated with CSI for medulloblastoma. Spine growth was measured on magnetic resonance imaging scans at defined locations on the basis of a published predictive model of spine growth after CSI. Differences between spine growth in the anterior, middle, and posterior aspect of the designated vertebral segments were also assessed. Differences between the groups treated with photons or electrons were assessed with student's t test.

RESULTS

A total of 19 patients (10 patients treated with electrons and 9 with photons) with a median follow-up time of 45.5 months (confidence interval, 34.9-55.1 months) were evaluated. Patients treated with electrons were younger than those who received photons (5.1 years [range, 3.8-9.0 years] vs 9.6 years [range, 3.5-12.9 years]); however, there were no differences in other clinical characteristics, treatment, or follow-up between the groups. Spine growth rate for patients treated with electrons fit the predictive model (104% ± 5.2%), but patients treated with photons had growth that was faster than predicted by the model (150% ± 47%) and different from that observed with electrons. The differences between treatment the modalities were statistically significant (P = .03). For patients treated with photons, there were no statistical differences between the growth rate of the anterior vertebral body compared with the posterior aspect, but for patients treated with electrons, a faster spine growth in the anterior L1-L5 lumbar spine was observed compared with the posterior lumbar spine (3.90 vs 2.52 mm/year; P = .006) without differences in the cervical or thoracic spine.

CONCLUSIONS

The use of electrons to treat the craniospinal axis in children with medulloblastoma resulted in no significant difference in spine growth compared with the predicted spine growth on the basis of previously published models using photons, but with a clinically insignificant faster spine growth rate in the anterior lumbar spine.

Bladder Preserving Trimodality Therapy for Muscle-Invasive Bladder Cancer

PURPOSE OF REVIEW

Here, we will review and summarize the current status and emerging data supporting the use of trimodality therapy as an alternative to cystectomy for patients with muscle-invasive bladder cancer.

RECENT FINDINGS

There are no randomized-controlled data comparing radical cystectomy with bladder preserving trimodality therapy available for comparison. However, observational data suggests acceptable bladder preservation and functional outcomes in patients receiving bladder preserving trimodality therapy as well as similar oncologic outcomes in select patients compared to radical cystectomy. Future trials are focusing on new techniques and novel therapeutics in patients with bladder cancer. Bladder preserving trimodality therapy results in satisfactory quality of life and comparable disease outcomes for select patients with muscle-invasive urothelial carcinoma of the bladder compared to cystectomy.

MDM2 Inhibition Sensitizes Prostate Cancer Cells to Androgen Ablation and Radiotherapy in a p53-Dependent Manner

PURPOSE: Increased murine double minute 2 (MDM2) expression, independent of p53 status, is associated with increased cancer-specific mortality for men with prostate cancer treated with radiotherapy. We assessed MI-219, a small molecule inhibitor of MDM2 with improved pharmacokinetics over nutlin-3, for sensitization of prostate cancer cells to radiotherapy and androgen deprivation therapy, a standard treatment option for men with high-risk prostate cancer. EXPERIMENTAL DESIGN: The effect of MDM2 inhibition by MI-219 was assessed in vitro and in vivo with mouse xenograft models across multiple prostate cancer cell lines containing varying p53 functional status. RESULTS: MDM2 inhibition by MI-219 resulted in dose- and time-dependent p53 activation and decreased clonogenic cell survival after radiation in a p53-dependent manner. Mechanistically, radiosensitization following inhibition of MDM2 was largely the result of p53-dependent increases in apoptosis and DNA damage as evidenced by Annexin V flow cytometry and γ-H2AX foci immunofluorescence. Similarly, treatment with MI-219 enhanced response to antiandrogen therapy via a p53-dependent increase in apoptotic cell death. Lastly, triple therapy with radiation, androgen deprivation therapy, and MI-219 decreased xenograft tumor growth compared with any single- or double-agent treatment. CONCLUSION: MDM2 inhibition with MI-219 results in p53-dependent sensitization of prostate cancer cells to radiation, antiandrogen therapy, and the combination. These findings support MDM2 small molecule inhibitor therapy as a therapy intensification strategy to improve clinical outcomes in high-risk localized prostate cancer. TRANSLATIONAL RELEVANCE: The combination of radiotherapy and androgen deprivation therapy is a standard treatment option for men with high-risk prostate cancer. Despite improvements in outcomes when androgen deprivation therapy is added to radiation, men with high-risk prostate cancer have significant risk for disease recurrence, progression, and even death within the first 10 years following treatment. We demonstrate that treatment with MI-219 (an inhibitor of MDM2) results in prostate cancer cell sensitization to radiation and androgen deprivation therapy in vitro and in vivo. Triple therapy with MI-219, radiation, and androgen deprivation therapy dramatically decreased tumor growth compared with any single- or double-agent therapy. These findings provide evidence that inhibition of MDM2 is a viable means by which to enhance the efficacy of both radiation and androgen deprivation therapy and thereby improve outcomes in the treatment of prostate cancer. As such, further investigation is warranted to translate these findings to the clinical setting.

Five Reasons to Consider Phytophthora infestans a Reemerging Pathogen

Phytophthora infestans has been a named pathogen for well over 150 years and yet it continues to "emerge", with thousands of articles published each year on it and the late blight disease that it causes. This review explores five attributes of this oomycete pathogen that maintain this constant attention. First, the historical tragedy associated with this disease (Irish potato famine) causes many people to be fascinated with the pathogen. Current technology now enables investigators to answer some questions of historical significance. Second, the devastation caused by the pathogen continues to appear in surprising new locations or with surprising new intensity. Third, populations of P. infestans worldwide are in flux, with changes that have major implications to disease management. Fourth, the genomics revolution has enabled investigators to make tremendous progress in terms of understanding the molecular biology (especially the pathogenicity) of P. infestans. Fifth, there remain many compelling unanswered questions.

Analysis of Left Atrial Respiratory and Cardiac Motion for Cardiac Ablation Therapy

Cardiac ablation therapy is often guided by models built from preoperative computed tomography (CT) or magnetic resonance imaging (MRI) scans. One of the challenges in guiding a procedure from a preoperative model is properly synching the preoperative models with cardiac and respiratory motion through computational motion models. In this paper, we describe a methodology for evaluating cardiac and respiratory motion in the left atrium and pulmonary veins of a beating canine heart. Cardiac catheters were used to place metal clips within and near the pulmonary veins and left atrial appendage under fluoroscopic and ultrasound guidance and a contrast-enhanced, 64-slice multidetector CT scan was collected with the clips in place. Each clip was segmented from the CT scan at each of the five phases of the cardiac cycle at both end-inspiration and end-expiration. The centroid of each segmented clip was computed and used to evaluate both cardiac and respiratory motion of the left atrium. A total of three canine studies were completed, with 4 clips analyzed in the first study, 5 clips in the second study, and 2 clips in the third study. Mean respiratory displacement was 0.2±1.8 mm in the medial/lateral direction, 4.7±4.4 mm in the anterior/posterior direction (moving anterior on inspiration), and 9.0±5.0 mm superior/inferior (moving inferior with inspiration). At end inspiration, the mean left atrial cardiac motion at the clip locations was 1.5±1.3 mm in the medial/lateral direction, and 2.1±2.0 mm in the anterior/posterior and 1.3±1.2 mm superior/inferior directions. At end expiration, the mean left atrial cardiac motion at the clip locations was 2.0±1.5 mm in the medial/lateral direction, 3.0±1.8 mm in the anterior/posterior direction, and 1.5±1.5 mm in the superior/inferior directions.

Less advanced disease at initiation of salvage androgen deprivation therapy is associated with decreased mortality following biochemical failure post-salvage radiation therapy

BACKGROUND

The optimal clinical context for initiation of salvage androgen deprivation therapy (SADT) following the biochemical recurrence of localized prostate cancer remains controversial. We chose to investigate if disease burden at time of SADT initiation is associated with clinical outcomes following biochemical failure (BF) post-salvage radiation therapy (SRT).

METHODS

Medical records of 575 patients receiving SRT at a single institution from 1986-2010 were retrospectively reviewed. Of 250 patients experiencing BF post-SRT, 172 had a calculable prostate-specific antigen doubling time (PSADT) prior to SADT initiation. These patients comprise the analyzed cohort and were divided into four groups based on characteristics at SADT initiation: those with PSADTs >3 months without distant metastasis (DM) (group 1 [less advanced disease], n=62), those with PSADTs <3 months without DM (group 2 [more advanced disease], n=28), those with DM (group 3 [more advanced disease], n=32), and those not receiving SADT during follow-up (group 4, n=50). Endpoints included prostate cancer-specific mortality (PCSM) and overall mortality (OM). Kaplan-Meier methods were used to estimate survival, and Cox proportional hazards models were used for multivariate analysis.

RESULTS

Median follow-up post-SRT was 7.9 years. Patients starting SADT with more advanced disease were at significantly increased risk for PCSM (hazard ratio [HR]:2.8, 95% confidence interval [CI]: 1.4-5.6, p=0.005) and OM (HR:1.9, 95% CI: 1.0-3.5, p=0.04) compared to those receiving SADT with less advanced disease. PCSM and OM did not significantly differ between groups 1 and 4 or groups 2 and 3. Of note, patients in group 4 had very long PSADTs (median = 27.0 months) that were significantly longer than those of group 1 (median = 6.0 months) (p<0.001). Multivariate analysis including groups 1-3 found a pre-SADT PSADT <3 months to be the most significant predictor of PCSM (HR:4.2, 95% CI: 1.6-11.1, p=0.004) and the only significant predictor of OM (HR:2.9, 95% CI: 1.3-6.7, p=0.01).

CONCLUSIONS

Less advanced disease at initiation of SADT is associated with decreased PCSM and OM following BF post-SRT; however, observation may be reasonable for patients with very long PSADTs. A PSADT <3 months prior to SADT initiation significantly predicts an increased risk of PCSM and OM in this patient demographic.

The impact of numeracy on verbatim knowledge of the longitudinal risk for prostate cancer recurrence following radiation therapy

OBJECTIVE

. Given the long natural history of prostate cancer, we assessed differing graphical formats for imparting knowledge about the longitudinal risks of prostate cancer recurrence with or without 'hormone' or 'androgen deprivation' therapy.

METHODS

. Male volunteers without a history of prostate cancer were randomized to 1 of 8 risk communication instruments that depicted the likelihood of prostate cancer returning or spreading over 1, 2, and 3 years. The tools differed in format (line, pie, bar, or pictograph) and whether the graph also included no numbers, 1 number (indicating the number of affected individuals), or 2 numbers (indicting both the number affected and the number unaffected). The main outcome variables evaluated were graphical preference and knowledge.

RESULTS

. A total of 420 men were recruited; respondents were least familiar and experienced with pictographs (P < 0.0001), and only 10% preferred this particular format. Overall accuracy ranged from 79% to 92%, and when assessed across all graphical subtypes, the addition of numerical information did not improve verbatim knowledge (P = 0.1). Self-reported numeracy was a strong predictor of accuracy of responses (odds ratio [OR] = 2.6, P = 0.008), and the impact of high numeracy varied across graphical type, having a greater impact on line (OR = 5.1; 95% confidence interval [CI] = 1.6-16; P = 0.04) and pie charts (OR = 7.1; 95% CI = 2.6-19; P =0.01), without an impact on pictographs (OR = 0.4; 95% CI = 0.1-1.7; P = 0.17) or bar charts (OR = 0.5; 95% CI = 0.1-1.8; P = 0.24).

CONCLUSION

. For longitudinal presentation of risk, baseline numeracy was strongly prognostic for outcome. However, the addition of numbers to risk graphs improved only the delivery of verbatim knowledge for subjects with lower numeracy. Although subjects reported the least familiarity with pictographs, they were one of the most effective means of transferring information regardless of numeracy.

Primary peritoneal clear cell carcinoma treated with IMRT and interstitial HDR brachytherapy: a case report

Primary peritoneal clear cell carcinoma (PP‐CCC), which is a rare tumor with poor prognosis, is typically managed with surgery and/or chemotherapy. We present a unique treatment approach for a patient with a pelvic PP‐CCC, consisting of postchemotherapy intensity‐modulated radiation therapy (IMRT) followed by interstitial high‐dose–rate (HDR) brachytherapy. A 54‐year‐old female with an inoperable pelvic‐supravaginal 5.6 cm T3N0M0 PP‐CCC tumor underwent treatment with 6 cycles of carboplatin and taxol chemotherapy. Postchemotherapy PET/CT scan revealed a residual 3.3 cm tumor. The patient underwent CT and MR planning simulation, and was treated with 50 Gy to the primary tumor and 45 Gy to the pelvis including the pelvic lymph nodes, using IMRT to spare bowel. Subsequently, the patient was treated with an interstitial HDR brachytherapy implant, planned using both CT and MR scans. A total dose of 15 Gy in 5 Gy fractions over two days was delivered with Ir‐192 HDR brachytherapy. The total prescribed equivalent 2 Gy dose (EQD2) to the HDR planning target volume (PTV) from both the EBRT and HDR treatments ranged between 63 and 68.8Gy2 due to differential dosing of the primary and pelvic targets. The patient tolerated radiotherapy well, except for mild diarrhea not requiring medication. There was no patient‐reported acute toxicity one month following the radiotherapy course. At four months following adjuvant radiation therapy, the patient had near complete resolution of local tumor on PET/CT without any radiation‐associated toxicity. However, the patient was noted to have metastatic disease outside of the radiation field, specifically lesions in the liver and bone. This case report illustrates the feasibility of the treatment of a pelvic PP‐CCC with IMRT followed by interstitial HDR brachytherapy boost, which resulted in near complete local tumor response without significant morbidity.

PACS number: 87.55.‐x