A New Prognostic Instrument for Predicting the Probability of Completion of Cisplatin during Chemoradiation for Head and Neck Cancer

Many head and neck cancer patients assigned to definitive or adjuvant chemoradiation treatment do not complete the concurrent cisplatin dose. We determined corresponding risk factors and developed a prognostic instrument to help identify these patients. Ten pre-treatment characteristics were retrospectively analyzed in 154 patients with head and neck cancer who were treated via chemoradiation with cisplatin. These pre-treatment characteristics included age, sex, Karnofsky performance score, tumor site, primary tumor stage, nodal stage, histologic grade, upfront surgery, human papilloma virus status, and history of smoking. The characteristics significantly associated with the completion of cisplatin-based treatment, the receipt of ≥80% cisplatin, or showing a strong trend of association after multivariate analyses were used for the prognostic instrument. For each characteristic, 0 points were assigned for worse outcomes, and 1 point was assigned for better outcomes. Patients' scores were calculated by adding these points. Age ≤ 60 years and a Karnofsky performance score of 90-100 were significantly associated with both endpoints after multivariate analysis, and male gender showed a trend for association with the receipt of ≥80% cisplatin. Patient scores were 0, 1, 2, and 3 points. The corresponding rates of completion of cisplatin-based treatment were 14%, 41%, 62%, and 72%, respectively (p = 0.004). The rates of receipt of ≥80% cisplatin were 29%, 54%, 72%, and 94%, respectively (p < 0.001). This new prognostic instrument helps to predict whether head and neck cancer patients scheduled for chemoradiation will receive cisplatin as planned.

A New Clinical Instrument for Estimating the Ambulatory Status after Irradiation for Malignant Spinal Cord Compression

Simple Summary

Since 2005, upfront surgery has been increasingly used in addition to radiotherapy for patients with malignant spinal cord compression (MSCC). As spinal surgery includes significant risks, careful patient selection is crucial. Individual risks and benefits should be considered when choosing an optimal treatment strategy. Benefits include preserving or regaining a patient’s ambulatory function. To facilitate the decision pro or contra upfront surgery, a new prognostic score was developed to predict ambulatory status after radiotherapy alone. This clinical score was created from data of patients previously treated in prospective trials. It includes three prognostic groups (17–21, 22–31, and 32–37 points) with post-radiotherapy ambulatory rates of 10%, 65%, and 97%, respectively. Patients of the 32–37 points group may not require upfront surgery. The new instrument achieved very high accuracy in predicting post-radiotherapy ambulatory and non-ambulatory status and was more precise than a previous prognostic score in predicting non-ambulatory status.

Abstract

Estimating post-treatment ambulatory status can improve treatment personalization of patients irradiated for malignant spinal cord compression (MSCC). A new clinical score was developed from data of 283 patients treated with radiotherapy alone in prospective trials. Radiotherapy regimen, age, gender, tumor type, interval from tumor diagnosis to MSCC, number of affected vertebrae, other bone metastases, visceral metastases, time developing motor deficits, ambulatory status, performance score, sensory deficits, and sphincter dysfunction were evaluated. For factors with prognostic relevance in the multivariable logistic regression model after backward stepwise variable selection, scoring points were calculated (post-radiotherapy ambulatory rate in % divided by 10) and added for each patient. Four factors (primary tumor type, sensory deficits, sphincter dysfunction, ambulatory status) were used for the instrument that includes three prognostic groups (17–21, 22–31, and 32–37 points). Post-radiotherapy ambulatory rates were 10%, 65%, and 97%, respectively, and 2-year local control rates were 100%, 75%, and 88%, respectively. Positive predictive values to predict ambulatory and non-ambulatory status were 97% and 90% using the new score, and 98% and 79% using the previous instrument. The new score appeared more precise in predicting non-ambulatory status. Since patients with 32–37 points had high post-radiotherapy ambulatory and local control rates, they may not require surgery.

Estimating the Probability of Not Completing the Intended Course of Thoracic Radiotherapy for Lung Cancer

BACKGROUND/AIM

In some patients with lung cancer scheduled for thoracic radiotherapy (RT), treatment is discontinued before reaching the planned dose. For optimal treatment personalization, a tool estimating whether a patient can complete radiotherapy would be helpful.

PATIENTS AND METHODS

Eleven pre-RT characteristics were analyzed in 170 patients receiving local RT for lung cancer. Characteristics included age, sex, tumor site, histology, tumor and nodal stage, distant metastasis, surgery, systemic treatment, pulmonary function, and smoking history.

RESULTS

Age >75 years (p=0.038), distant metastasis (p=0.009), and forced expiratory volume in 1 second <1.2 l (p=0.038) were significantly associated with discontinuation of RT. A prognostic instrument was developed in 126 patients with complete data regarding these characteristics. It included three groups (0, 1, and 2-3 points) with non-completion rates of 33.3%, 55.0% and 75.0% (p=0.004).

CONCLUSION

This new instrument can help estimating the probability that lung cancer patients assigned to local RT cannot complete the planned course of RT.

Predicting the Risk of Subsequent Distant Brain Metastases After Stereotactic Radiosurgery or Fractionated Stereotactic Radiotherapy in Elderly Patients

BACKGROUND/AIM

Treatment for elderly patients with few brain metastases is controversial. A score was generated to predict distant brain metastases (DBMs) after stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT).

PATIENTS AND METHODS

Ten characteristics were retrospectively analyzed for freedom from new DBMs in 104 elderly patients receiving SRS or FSRT alone for 1-3 brain metastases. Characteristics that were significant or showed a trend on multivariate analysis were used for the score.

RESULTS

On multivariate analysis, favorable histology (p=0.026) and single brain metastasis (p=0.006) showed significant associations with freedom from DBMs. A trend was found for supra-tentorial location only (p=0.065). Three groups were designed, 10-14, 16-20 and 21-25 points, with 6-month rates of freedom from DBMs of 10%, 54% and 95%, respectively (p<0.0001). Positive predictive values to predict DBMs and freedom from DBMs at 6 months were 91% and 94%.

CONCLUSION

This new score provided high accuracy in predicting DBMs and freedom from DBMs.

An Instrument for Estimating the 6-Month Survival Probability After Whole-brain Irradiation Alone for Cerebral Metastases from Gynecological Cancer

BACKGROUND/AIM

Patients with cerebral metastases from gynecological cancer who receive whole-brain irradiation (WBI) alone require personalized therapy. This study contributes to personalized care by creating an instrument to predict 6-month survival probability.

PATIENTS AND METHODS

In 49 patients, six pre-treatment variables, namely age, Eastern Cooperative Oncology Group performance score (ECOG-PS), primary tumor type, number of cerebral metastases, metastasis outside the brain, and interval between diagnosis of gynecological cancer and WBI, were analyzed for survival.

RESULTS

Of the six pre-treatment variables, ECOG-PS was significantly associated with survival (p=0.014) and metastasis outside the brain showed a trend for association (p=0.096). Six-month survival rates divided by 10 resulted in scores of 0, 2 or 7 points for ECOG-PS and of 2 or 7 points for metastasis outside the brain. Scores for individual patients were 2, 4, 7, 9 or 14 points. Three groups were created, those with 2-7, 9 and 14 points, with 6-month survival rates of 10%, 53% and 100%, respectively (p=0.004).

CONCLUSION

An instrument was designed to predict the 6-month survival of patients receiving WBI for cerebral metastases from gynecological cancer and facilitate personalized care.

Therapy of the burnout syndrome

Background

The prevalence, diagnostics and therapy of the burnout syndrome are increasingly discussed in the public. The unclear definition and diagnostics of the burnout syndrome are scientifically criticized. There are several therapies with unclear evidence for the treatment of burnout in existence.

Objectives

The health technology assessment (HTA) report deals with the question of usage and efficacy of different burnout therapies.

Methods

For the years 2006 to 2011, a systematic literature research was done in 31 electronic databases (e.g. EMBASE, MEDLINE, PsycINFO). Important inclusion criteria are burnout, therapeutic intervention and treatment outcome.

Results

17 studies meet the inclusion criteria and are regarded for the HTA report. The studies are very heterogeneous (sample size, type of intervention, measuring method, level of evidence). Due to their study design (e.g. four reviews, eight randomized controlled trials) the studies have a comparable high evidence: three times 1A, five times 1B, one time 2A, two times 2B and six times 4. 13 of the 17 studies are dealing with the efficacy of psychotherapy and psychosocial interventions for the reduction of burnout (partly in combination with other techniques). Cognitive behaviour therapy leads to the improvement of emotional exhaustion in the majority of the studies. The evidence is inconsistent for the efficacy of stress management and music therapy. Two studies regarding the efficacy of Qigong therapy do not deliver a distinct result. One study proves the efficacy of roots of Rhodiola rosea (evidence level 1B). Physical therapy is only in one study separately examined and does not show a better result than standard therapy.

Discussion

Despite the number of studies with high evidence the results for the efficacy of burnout therapies are preliminary and do have only limited reach. The authors of the studies complain about the low number of skilled studies for the therapy of burnout. Furthermore, they point to the insufficient evaluation of the therapy studies and the need for further research. Some authors report the effects of considerable natural recovering.

Numerous limitations affect the quality of the results. Intervention contents and duration, study design and study size are very diverse and do not permit direct comparison. Most of the samples are small by size with low statistical power, long-term follow-ups are missing. Comorbidities and parallel utilized therapies are insufficient documented or controlled. Most of the studies use the Maslach Burnout Inventory (MBI) as diagnostic or outcome-tool, but with different cut-off-points. It should be noticed that the validity of the MBI as diagnostic tool is not proved. Ethical, juridical and social determining factors are not covered or discussed in the studies.

Conclusion

The efficacy of therapies for the treatment of the burnout syndrome is insufficient investigated. Only for cognitive behavioural therapy (CBT) exists an adequate number of studies which prove its efficacy. Big long-term experimental studies are missing which compare the efficacy of the single therapies and evaluate their evidence. The natural recovering without any therapy needs further research. Additionally, it has to be examined to what extent therapies and their possible effects are thwarted by the conditions of the working place and the working conditions.