Insurance Request and Approval Process for Proton Beam Therapy in Patients with Esophageal Cancer

PURPOSE/OBJECTIVE(S)

Randomized data suggests proton beam therapy (PBT) reduces the risk and severity of toxicities when compared to IMRT in the neoadjuvant or definitive setting for esophageal cancer. As a critical barrier to access to PBT, we investigate our institutional experience with the prior authorization (PA) process for patients (pts) with esophageal cancer.

MATERIALS/METHODS

One hundred and four (104) consecutive pts with esophageal cancer from 2016-2020 at one institution for whom PBT was recommended were analyzed. Data was collected from the customer relations management (CRM) database and electronic health record. Patient characteristics, tumor characteristics, treatment parameters, types of insurance, and clinical outcomes (OS, LF, DF) were recorded. Timepoints of the steps of the PA process included the PA team's initial inquiry, the initial decision, first through third appeals, and outcomes of each appeal (the third of which was regarded as the final decision). Rates of approval and successful appeal were calculated. Logistic and Cox regression models were used to evaluate whether insurance decisions were associated with clinical factors or clinical outcomes.

RESULTS

Approval rates by Medicare (n = 68) and private insurance (n = 36) were 100 and 42% on initial request, at a median (range) 0 and 3 (0-15) days from inquiry to determination, respectively. All 21 pts initially denied coverage appealed the decision. Overall, denial was overturned in 48% of pts (median [range] time, 14 [7-36] days from initial inquiry [FIQ]), i.e., PBT was eventually approved for them. The remaining pts proceeded with self-pay or photon therapy. Upon first appeal, 14 pts were denied (median [range] time, 7 [1-26] days FIQ). Upon second appeal, 6 pts were denied (median [range] time, 18 [7-34] days FIQ). Finally, upon third appeal, 2 pts were denied and 1 patient was approved (median [range] time, 2 [20-39] days). Medicare insurance (P < .01) and possessing secondary insurance (P = .02) were found to be associated with increased likelihood of initial approval. Notably, a trend was found between clinical trial enrollment and decreased likelihood of initial approval. Neither initial nor final insurance decisions were found to be associated with OS, LF, or DF.

CONCLUSION

Despite randomized data and policy efforts supporting the use of PBT in esophageal cancer, pts with private payers experience treatment delays and often eventual denial after appeal.

Quality and Safety Considerations in Image Guided Radiation Therapy: An ASTRO Safety White Paper Update

PURPOSE/OBJECTIVE(S)

This updated report on image guided radiation therapy (IGRT) is based on a consensus-based white paper previously published by the American Society for Radiation Oncology (ASTRO) addressing patient safety. In the past decade, IGRT technology and procedures have progressed significantly and are now more commonly used. The use of IGRT has now extended beyond high-precision treatments, such as stereotactic radiosurgery and stereotactic body radiation therapy, and into routine clinical practice for many treatment techniques and anatomic sites. Therefore, quality and treatment planning and delivery considerations for these techniques are paramount for patient safety.

MATERIALS/METHODS

In 2021, ASTRO convened an interdisciplinary task force to assess the original IGRT white paper and update content where appropriate. Recommendations were created using a consensus-building methodology, and task force members indicated their level of agreement based on a 5-point Likert scale from "strongly agree" to "strongly disagree." A prespecified threshold of ≥75% of raters who selected "strongly agree" or "agree" indicated consensus.

RESULTS

The IGRT white paper was published (Pract Radiat Oncol. 2022 Dec) and endorsed by the American Association of Physicists in Medicine (AAPM), American Association of Medical Dosimetrists, and American Society of Radiologic Technologists. Since the first IGRT paper was published by ASTRO in 2013, significant technological advancement has taken place. New and updated considerations in personnel requirements, staffing, education and training, equipment and technological requirements, quality management and assurance, IGRT program management, and safety considerations were reported. A 17-point consensus was reached and recommended in 5 areas surrounding program development, quality assurance, quality management, treatment delivery, and vendor engagement (Table 5, Summary of key recommendations).

CONCLUSION

This IGRT white paper builds on the previous version and uses other guidance documents to primarily focus on processes related to quality and safety. IGRT requires an interdisciplinary team-based approach, staffed by appropriately trained specialists, as well as significant personnel resources, specialized technology, and implementation time. A thorough feasibility analysis of resources is required and should be discussed with all personnel before undertaking new imaging techniques. A comprehensive quality-assurance program must be developed to ensure IGRT is performed safely and effectively. As IGRT technologies continue to improve or emerge, existing practice guidelines should be updated regularly according to the latest AAPM Task Group reports. Patient safety in the application of IGRT is everyone's responsibility, and professional organizations, regulators, vendors, and end-users must demonstrate strong commitments to ensure that the highest levels of safety are achieved.

Patient-Reported Adverse Effects in 15-Fraction Pancreatic Cancer Radiation Therapy

PURPOSE/OBJECTIVE(S)

Fifteen-fraction radiotherapy (RT) regimens have emerged as a standard option in the treatment of patients with pancreas cancer. Patient-reported outcomes (PROs) during and after pancreas cancer RT have not been well characterized. There is an even greater paucity of data among patients treated with 15-fraction regimens. We aimed to characterize gastrointestinal (GI) PROs in a cohort of patients treated with 15-fraction pancreas RT.

MATERIALS/METHODS

This was an IRB-approved retrospective cohort study including patients with primary pancreas tumors treated with pre-operative or definitive 15-fraction RT from 2013 to 2022. PROs, including anorexia, nausea, diarrhea, stool incontinence, and abdominal pain, were prospectively collected and characterized per PRO-common terminology criteria for adverse events (PRO-CTCAE). Acute PROs were defined as occurring during RT through 110 days post-RT but prior to oncological surgery. Grade 3 or 4 PROs were respectively scored as "quite a bit" or "very much" in symptom interference questions, "frequently" or "almost constantly" in symptom frequency questions, and "severe" or "very severe" in symptom severity questions.

RESULTS

A total of 330 patients were analyzed. Patient characteristics included a median age of 67 years (IQR: 60 - 72), ECOG 0-1 (96%), and male sex (56%). Most patients had pancreatic ductal adenocarcinoma (96%). Resectability status included resectable (12%), borderline resectable (46%), and locally advanced (42%). 37% had lymph node involvement. 97% of patients received neoadjuvant chemotherapy and 98% received concurrent chemotherapy, most commonly with 5-fluorouracil or capecitabine (88%) or gemcitabine (11%). 99% were treated with intensity modulated RT. Median RT dose was 4500 cGy (IQR 4500 - 4500) to gross disease with margin and 3750 cGy (IQR 3750 - 3750) to elective nodal regions. 59% proceeded with oncologic resection. Grade 3 or higher acute PROs are demonstrated in the table.

CONCLUSION

Often considered more sensitive than physician assessments, PROs provide vital metrics that allow for a better understanding of the patient experience during cancer treatment. We report a comprehensive assessment of prospectively collected PROs per standardized PRO-CTCAE with the goals of raising awareness of the patient experience during 15-fraction pancreas cancer RT and helping guide future clinical trial designs focused on patient quality of life endpoints.

Determining the Minimal Clinically Important Difference of the FACT-E to Evaluate the Change in the Quality of Life of Patients with Esophageal Cancer Treated with Curative Radiotherapy

PURPOSE/OBJECTIVE(S)

Patients with esophageal cancer (EC) are often treated with radiotherapy (RT). The Functional Assessment of Cancer Therapy-Esophageal (FACT-E) is a health-related quality of life (QOL) instrument validated in patients with EC. The aim of this study was to determine the minimal clinically important difference (MCID) for FACT-E subscales, to allow for meaningful evaluation of the effect of RT on EC patient's QOL.

MATERIALS/METHODS

We evaluated patients with EC, treated with curative intent RT, who completed the FACT-E at baseline and end of treatment (EOT). We calculated the MCID for the FACT-E subscales using anchor-based and distribution-based approaches. In the anchor-based approach we determined improvement and deterioration based on the overall health assessment from the PROMIS-10 as the anchor. We modeled the change in domain scores with age-adjusted regressions to determine the difference in classifications. For distribution-based analysis, we considered 0.3 and 0.5 standard deviation (SD). We averaged MCID for improvement and deterioration separately across timepoints, by approach, and we report MCID ranges as the minimum and maximum values across methods.

RESULTS

Our cohort included 210 patients with EC, 96.7% white, 85.7% males, and 32.9% treated with photon with a median dose of 50 Gy (IQR 50-50) and a median fraction number of 25(IQR 25,25). The median age at RT was 67.6 years (IQR 60.9,73.7). The social domain had the lowest MCID (deterioration and improvement 0.9-1.9), while the widest MCID range, proportionally to the measure, was associated with the Fact-E total score (2.1-5.6 for improvement, and 3.7-5.6 for deterioration). MCID estimates from 0.3 SD were in exact agreement with the anchor-based deterioration estimates for the physical domain (2.3), and improvement estimates for the Trial Outcome Index (6.1).

CONCLUSION

We determined the MCID for the FACT-E domains, using a combination of anchor- and distribution-based approaches. These findings are critical to determine whether there is meaningful change in the QOL of individuals with EC treated with curative RT.

Characterizing Hospital Admissions after Proton Beam Therapy Using the National Inpatient Sample Database

PURPOSE/OBJECTIVE(S)

To characterize the diagnoses, comorbidities, and length of stay in patients who received proton beam therapy during their hospital stay as part of their cancer treatment regimen.

MATERIALS/METHODS

The National Inpatient Sample database was queried using ICD-10 codes to identify all hospitalizations with proton beam therapy between 2016 and 2018. Weighted frequencies for categorical variables and geometric mean with standard error for continuous variables were derived. Generalized linear models for clustered data in SAS v 9.4 (Cary, NC) were used to determine the association between length of stay with patient and hospital baseline characteristics.

RESULTS

We studied 511 patients, representing a weighted estimate of 2,555 patients from the National Inpatient Sample from 2016 to 2018 who received proton beam therapy during hospitalization. The mean age was 40 years (StdErr = 3.0). The estimated average length of stay was 7.7 days (StdErr = 0.4). The cohort was 53.6% White, 15.3% Black, 10.4% Hispanic, 7.0% Asian or Pacific Islander, and 0.2% Native American. The most frequent diagnoses at admission were encounter for antineoplastic chemotherapy (10.0%), secondary malignant neoplasm of brain (9.2%), secondary malignant neoplasm of bone (9.0%), encounter for antineoplastic radiation therapy (6.1%), and neoplasm-related pain (3.3%). Large- and medium-sized hospitals were associated with significantly longer lengths of stay than small-sized hospitals (p<0.0001 and p = 0.0186, respectively). Compared to private investor-owned (proprietary) hospitals, nonfederal government-owned (public) hospitals are associated with prolonged length of stay (p = 0.0033). Hospital region and patient age, race, sex, comorbidity, and income quartile were not associated with a longer length of stay.

CONCLUSION

Our findings demonstrate that hospital-level characteristics are more important than patient-level characteristics in predicting length of stay in patients undergoing proton beam therapy while hospitalized. Patients undergoing proton beam therapy while hospitalized at large- and medium-sized hospitals had longer lengths of stay than those at small-sized hospitals. Additionally, publicly owned hospitals were associated with prolonged length of stay compared to private hospitals. The underlying reason for this difference in length of stay is unclear but may suggest different management strategies, protocols, and discharge criteria for patients receiving proton beam therapy in larger and publicly-owned hospitals compared to smaller and privately-owned hospitals. Future investigations should explore the underlying causes for these discrepancies and identify potential strategies to shorten unnecessarily prolonged hospital stays in patients undergoing proton beam therapy.

Chemoimmunotherapy for the treatment of extensive-stage small cell lung cancer (ES-SCLC) in patients with an Eastern Cooperative Group (ECOG) performance status (PS) of two or greater

8569

Background: Immune checkpoint inhibitor (atezolizumab or durvalumab) combined with platinum-etoposide is the standard first-line therapy for patients with extensive-stage small cell lung cancer (ES-SCLC). The phase III clinical trials that led to the approval of chemoimmunotherapy in ES-SCLC, excluded patients with an Eastern Cooperative Group (ECOG) Performance Status (PS) of Two or Greater. Therefore, data on efficacy of this combination in this subgroup of ES-SCLC patients whose performance status two or greater is limited. Methods: A retrospective analysis was performed of patients diagnosed with ES-SCLC who received chemoimmunotherapy (atezolizumab or durvalumab) within the Mayo Clinic Health System between January 2016 and January 2021. Cases were identified from clinical databases at Mayo Clinic. Data on demographics, ECOG-PS, date of diagnosis, date of progression, whole brain radiation, CNS involvement, liver involvement, stereotactic body radiation, chest consolidation, platinum sensitivity, lines of therapy and last follow up date were extracted. Overall Survival (OS) and progression free survival (PFS) for ECOG-PS 2-3 were compared to patients with an ECOG-PS 0-1. Results: A total of 84 patients were identified with a median age of 68.2 (48-88) years old. Of these, 54 patients were identified with an ECOG-PS 0-1 and 30 patients with an ECOG-PS 2-3. The median PFS for the ECOG PS 0-1 cohort was 5.2 months (95% CI 4.6-6.1) while the median PFS for the ECOG-PS 2-3 cohort was 6.0 months (95% CI 4.2-7.7; logrank p = 0.93). The median OS for the ECOG-PS 0-1 cohort was 10.8 months (95% CI 8.5-12.9) while the median OS for the ECOG-PS 2-3 cohort was 10.3 months (95% CI 6.0-14.1; logrank p = 0.39). Hazard ratios of ECOG-PS 0-1 versus 2-3 showed no tendency of increased PFS or OS for either group within cox proportional hazards models. Forty-three percent of ECOG-PS 0-1 achieved a partial response (PR) and 57% of patients who had ECOG-PS 2-3 also achieved a PR (Fisher’s exact p = 0.23). A complete response was found in 4% of ECOG-PS 0-1 compared to 3% in the ECOG-PS 2-3 cohort. For patients who responded to initial therapy, 46% of ECOG-PS 2-3 patients had a platinum sensitive relapse while only 33% of ECOG-PS 0-1 were still platinum sensitive at the time of relapse. Five ECOG-PS 2-3 patients were able to receive a second-line therapy. Conclusions: To our knowledge, this is the first study to evaluate chemoimmunotherapy in the subgroup of ES-SCLC patients with an ECOG-PS 2 or greater. This retrospective study demonstrated no significant difference in PFS, OS, and ability to achieve a least a PR in ECOG-PS 2-3 cohort when compared to ECOG-PS 0-1. Therefore, chemoimmunotherapy should not be reserved for only an ECOG-PS of 0-1 but should be considered for all treatment eligible patients.

Clinical outcome associated with neoadjuvant chemoradiation and orthotopic liver transplantation versus definitive chemoradiation in 49 patients with unresectable, hilar, or extrahepatic cholangiocarcinoma

494

Background: Our aim was to compare survival between patients receiving neoadjuvant chemoradiation and orthotopic liver transplantation (OLT group) versus definitive chemoradiation (CRT group) for extrahepatic or hilar cholangiocarcinoma. Methods: 49 patients (20 in OLT group vs. 29 in CRT group) with unresectable hilar/extrahepatic cholangiocarcinoma were treated at Mayo Clinic Arizona between Feb. 1998–Sep. 2019. Treatment included external beam radiation therapy (median 4500cGy) and boost (median 900cGy) with either continuous 5-flurouracil (dose range 180–225 mg/m2) or capecitabine (dose range 825–1000 mg/m2 BID) prior to or without OLT. Radiation boosts were delivered with EBRT or bile duct brachytherapy. Patients were between 27.9–84.3 years (median 64.3) at diagnosis. 18 patients had previous diagnosis of PSC. Results: Between Feb. 1998–Sep. 2019, 31(63%) of 49 patients died by the end of follow-up. Of patients treated with neoadjuvant therapy and OLT, 7(35%) of 20 patients died. 24(86%) of 28 patients treated with definitive therapy died. The OLT cohort were younger (mean age 56.5 vs. 69.0 years), more likely to have PSC and UC (65% vs. 17%), and had a lower CA 19-9 (median 43 vs. 535)(P < 0.003). From the end date of radiation, median overall survival was 76.8 months vs. 15.6 months for the OLT and CRT groups, respectively. Survival rates at 3 and 5 years were 78% and 69% in the OLT group compared to 19% and 6% in the CRT group (HR 7.73; 3.04-19.65:(P < 0.0001)). Progression-free survival (89% vs. 30% at 3 years), and distant metastasis-free survival (88% vs. 66% at 3 years) favored OLT versus CRT alone (HR 5.74;1.12-29.34:(P < 0.02)). Univariate analysis demonstrated that the method of treatment (OLT vs. CRT) was the only variable associated with better clinical outcomes. Conclusions: In patients with unresectable extrahepatic/hilar cholangiocarcinoma, survival was higher in those who underwent chemoradiation and OLT. Patients who received definitive chemoradiation in the absence of OLT were expected to have worse overall, progression-free, and metastasis-free survival.

Dosimetric analysis of distal esophageal adenocarcinoma patients treated by intensity-modulated proton therapy with small spot size

159

Background: Intensity-modulated proton therapy (IMPT) with small spot size has the potential to reduce dose to normal tissues but also introduces new confounding factors such as setup uncertainty, range uncertainty, and interplay effects due to breathing motion. We investigated plan quality and robustness of IMPT with small spot size for distal esophageal adenocarcinoma (DEA). Methods: 19 patients with DEA treated by IMPT were retrospectively evaluated. Spot sizes ranged from 2 to 6mm, with spot spacing of 5mm. All plans were generated using a commercial treatment planning system. In-house-developed dose-evaluation software modeled time-dependent spot delivery to incorporate interplay effects. Dose-volume-histogram (DVH) indices were used to evaluate plan quality and robustness was evaluated using the DVH band method. Results: For plan quality, median values of clinical target volume D95% and D5%-D95% (normalized to the prescribed doses), total lung mean dose, heart mean dose, and cord Dmax were 1.014, 0.035, 3.82Gy[RBE], 7.73Gy[RBE], 39.16Gy[RBE], respectively. For plan robustness, median band widths of the aforementioned DVH indices were 0.018, 0.048, 0.60Gy[RBE], 4.17Gy[RBE], and 2.36Gy[RBE], respectively. For interplay effects, median values of the aforementioned DVH indices were 0.99, 0.061, 4.07Gy[RBE], 7.87Gy[RBE], and 39.66Gy[RBE], respectively. Seven patients underwent esophagectomy after neoadjuvant chemoradiation, and five, three, and one of them achieved downstaging, near complete response, and pathologic complete response, respectively; R0 resection was achieved in all cases. For all patients, acute side effects were mostly limited to grades 1-2 only. The only grade 3 adverse events were related to feeding tube placement (8 patients); there were no RT-induced pneumonitis or other lung-related toxicities. Conclusions: IMPT plans with small spot size for DEA have good target dose coverage, homogeneity and normal tissue protection. Treatment plans are also robust to uncertainties and interplay effects. Early clinical results demonstrate low acute toxicity and encouraging clinical and pathologic response.

Relationship of initial quality-of-life deficit and survival in esophageal cancer (EC): The Mayo Clinic Romero Registry experience

97

Background: A diagnosis of EC significantly impairs patient (pt)’s survival and quality of life (QoL). We explored the relationship between pt-assessed QoL and survival. Methods: The Mayo Clinic Romero (formerly Esophageal Adenocarcinoma-Barrett's Esophagus) Registry prospectively collects clinical data during a pt's treatment course. QoL is recorded at enrollment (baseline) and annually using a validated 12-item Linear Analog Self-Assessment (LASA). A 10-pt scale is applied; ≤5 was termed clinically deficient QoL. Initial TNM staging, clinical (age, sex, prior chemotherapy, and esophagectomy), and socioeconomic variables (marital/employment status) were analyzed using Cox proportional hazards regression models. Results: 836 pts were analyzed. Median age was 64 years. 166, 506 and 164 pts had early, locally advanced, and metastatic EC, with 5-year survival rates of 75.1%, 33.6%, and 8.1%, respectively (P≤.0001). Poorer survival rates were seen in clinically QoL deficient pts in the following categories: Overall QoL (Hazard Ratio [H.R.] 0.66; 95% C.I., 0.54-0.80; P≤.0001) and LASA subsets for physical (H.R. 0.68; 95% C.I., 0.57-0.82; P≤.0001), emotional well-being (H.R. 0.69; C.I., 0.57-0.84; P=.0003), and social activity (H.R. 0.76; C.I., 0.63-0.91; P=.0028). No difference in survival was observed for marital or employment status, familial support, and financial/legal concerns. Pts with esophagectomy prior to LASA evaluation had improved survival (H.R. 0.68; 95% C.I., 0.55-0.85; P=.0005). No survival difference was observed whether pts received chemotherapy, before or after their baseline LASA evaluation. Conclusions: A strong association exists between pt’s overall survival and better overall QOL, physical, emotional well-being, and social activities. Using LASA to clinically monitor QoL at specified intervals may afford providers the opportunity to intervene when patients begin to experience QoL decline. The determinants of clinically deficit QoL and its impact on survival warrant further translational and prospective research.