An Analysis of Cancer Center-Provided Rideshare Utilization for Radiation Therapy.

OBJECTIVES: The potential of rideshare services to facilitate timely radiation therapy (RT), especially for resource-limited patients, is understudied. METHODS: Patients (n = 63) who received 73 courses of RT (1,513 fractions) and utilized free hospital-provided rideshare service (537 rides) were included in this retrospective study. A multidimensional analysis was conducted including a comparison of demographic, disease characteristics, and treatment completion data; a revenue analysis to evaluate the financial impact of rideshare services; and a geospatial analysis to evaluate community-level characteristics of patients. RESULTS: Median age was 59; most were female (56%) and self-identified as Black or African American (56%), not working (91%), not partnered (83%), high school educated or less (78%), and insured with Medicaid (51%). Geospatial analysis revealed that patients lived in communities with significantly higher rates of resource deprivation. Median rideshare distance was 6.4 miles (interquartile range 3.4-11.2) with a median cost of $13.04 per rideshare (interquartile range 9-19). Of the rideshare-facilitated treatments, 100% were completed, with an overall course completion rate of 97.3% compared with 85.4% for those who did not use rideshare (P = .001); two patients discontinued RT for reasons unrelated to transportation. High rideshare utilization (n = 32), defined as utilization ≥ 45% of the treatment course, was associated with significantly shorter treatment courses and lower radiation doses compared with low rideshare utilization (P = .04). Total rideshare cost for high utilizers and whole cohort was $11,589 and $16,895, facilitating an estimated revenue of $401,952 and $1,175,119, respectively. CONCLUSIONS: Free hospital-provided rideshare service is economically feasible and associated with high RT completion rates. It may help enhance quality radiation care for those who come from resource-limited communities.

ECOG-ACRIN Guideline for Contouring and Treatment of Early Stage Anal Cancer Using IMRT/IGRT.

PURPOSE: Previous anal cancer guidelines delineate target volumes similarly for all patients with squamous cell carcinoma of the anal canal and/or perianal skin (SCCA), regardless of disease stage. The purpose of this guideline is to provide customized radiation treatment recommendations for early stage (T1-2 N0 M0) anal cancer treated with intensity modulated and image guided radiation therapy (RT). METHODS AND MATERIALS: A contouring atlas and radiation treatment recommendations for the ongoing, randomized phase II trial of deintensified chemoradiation for early stage SCCA (EA2182) was created by an expert panel of radiation oncologists. A literature search was conducted to update and expand these recommendations into a guideline for routine clinical use. RESULTS: For the majority of cases, we recommend treatment in the supine, frog leg position with the use of a customized immobilization device and daily image guided RT to ensure optimal bone and soft tissue alignment. Vaginal dilators can be used daily during RT to maximize genitalia sparing. We recommend use of a 10-mm margin on the gross tumor plus including the anal complex to create the primary clinical target volume. To define the elective lymph node clinical target volume, we recommend starting with a 7-mm expansion on blood vessels, but then further refining these volumes based on the anatomic location. A 5- to 10-mm planning target volume (PTV) margin is suggested based on institutional setup and patient-specific factors. When using a simultaneous integrated boost technique, a dose of 50.4 Gy to primary PTV and 42 Gy to lymph node PTV, both delivered over 28 fractions, with chemotherapy is appropriate for early stage anal cancer. CONCLUSIONS: This guideline provides anatomic, clinical, and technical instructions to guide radiation oncologists in the planning and delivery of intensity modulated and image guided RT for early stage SCCA.

Proton Beam Therapy for Locally Advanced Head and Neck Tumors: An Analysis of Dosimetric and Clinical Outcomes.

OBJECTIVE: Locally advanced tumors of the head and neck region often lie in close proximity to critical organs at risk (OARs). Providing effective treatment coverage to these malignancies while minimizing radiation dose to surrounding OARs is advantageous. Our aim is to compare dosimetric data of OARs from proton beam therapy (PBT) plans to volumetric modulated arc therapy (VMAT) treatment plans, and to evaluate clinical outcomes in patients treated with PBT. METHODS: We identified patients with locally advanced head and neck tumors treated with PBT at our institution from 2016 to 2019. Study endpoints included mean and maximum doses for the OAR structures for each treatment plan, overall survival, time to local-regional or distant progression, and presence of acute and late toxicities. Mean and maximum doses to OAR structures were compared between treatment modalities using a paired Wilcoxon signed-rank test. P-values <0.05 were considered significant. RESULTS: A total of 42 patients were identified. Clinical target volume coverage was >95% for both PBT and VMAT plans. PBT plans showed a significant reduction to the mean doses to all OARs, and max doses to most OARs (P<0.05). The largest reduction mean dose was seen in the contralateral cochlea and parotid glands at 71% and 75%, respectively. Median follow-up was 27 months. Overall survival at 4 years was 44.75%. Freedom from local-regional progression was 73.28% at 2 years. The majority of patients developed Common Terminology Criteria for Adverse Events (CTCAE) grade I dermatitis, mucositis, or both. CONCLUSIONS: PBT resulted in meaningful dose reductions to OARs while maintaining comparable target coverage when compared with VMAT plans. Further refinements to proton therapy may have the potential to further minimize dose to critical structures.

Telemedicine Use and Satisfaction Among Radiation Oncologists During the COVID-19 Pandemic: Evaluation of Current Trends and Future Opportunities.

PURPOSE: During the COVID-19 pandemic, telemedicine became an attractive alternative to in-person appointments. The role of telemedicine in patients who undergo frequent on-site treatment, such as radiation therapy, is unclear. The purpose of this study was to examine telemedicine use, physician satisfaction, and barriers to continued use in radiation oncology. METHODS AND MATERIALS: An anonymous, electronic survey was distributed to radiation oncologists internationally between June and October 2020. Respondents described demographic and practice characteristics, and a 5-point Likert scale assessed provider satisfaction, ease of use, and overall utility of telemedicine. Analyses include descriptive statistics and subgroup comparisons using the χ2 test and Fisher's exact test. RESULTS: The response rate was 4.3%. Two hundred thirty-two respondents completed the survey, 63.8% of whom were male, 52.6% aged 50 or younger, and 78.0% from the United States. Only 14.2% used telemedicine previously, which increased to 93.1% during COVID-19. Among all telemedicine users, usage rates were 77.9% for initial consultations, 97.2% for follow-up visits, and 35.9% for on-treatment visits. Of the respondents, 69.8% reported that <25% of patients requiring treatment experienced delays due to COVID-19. Most conducted appointments from the workplace, with 40.1% also doing so from home. Satisfaction was high at 73.8%, perceived usefulness was 76.9%, and 81.5% hope to continue using telemedicine after the pandemic. However, 82.4% had concerns with the inability to examine patients and 63.0% had concerns about poor patient access to the required technology. In addition, 49.5% had concerns regarding continued billing/reimbursement, less commonly at government centers (18.8%) compared with academic/satellite facilities (52.7%) and free-standing centers/community hospitals (50.7%, P = .039 for both comparisons). These concerns were also significantly higher among US physicians (53.2% vs 34.9%, P = .048). CONCLUSIONS: Widespread adoption of telemedicine by radiation oncologists occurred during COVID-19 with high rates of satisfaction and interest in continued use. Sustained reimbursement for telemedicine services is a significant concern, particularly in the United States and outside of government facilities.

Thyroid-optimized and thyroid-sparing radiotherapy in oral cavity and oropharyngeal carcinoma: A dosimetric study.

BACKGROUND: Radiation-induced hypothyroidism is a common toxicity of head and neck radiation. Our re-planning study aimed to reduce thyroid dose while maintaining target coverage with IMRT. METHODS: We retrospectively identified patients with oral-cavity (n = 5) and oropharyngeal cancer (n = 5). Treatment plans were re-optimized with 45 Gy thyroid mean dose constraint, then we cropped the thyroid out of PTVs and further reduced thyroid dose. Target coverage was delivering 100% dose to ≥ 93% of PTV and 95% of dose to > 99% of PTV. RESULTS: Originally, average mean dose to thyroid was 5580 cGy. In model I, this dropped to 4325 cGy (p < 0.0001). In model II, average mean dose was reduced to 3154 cGy (p < 0.0001). For PTV low and PTV int, all had acceptable target coverage. CONCLUSION: In patients with oral-cavity and oropharyngeal cancers, mean dose could be significantly reduced using a thyroid-optimized or thyroid-sparing IMRT technique with adequate coverage.

Stereotactic body radiotherapy (SBRT) for T2N0 (>3 cm) non-small cell lung cancer: Outcomes and failure patterns.

PURPOSE/OBJECTIVES: Outcomes of T2N0 lung cancer patients treated with stereotactic radiotherapy are not well known. METHODS AND MATERIALS: We conducted a single institution retrospective review of patients with T2N0 NSCLC who were treated with SBRT. The local, regional, distant control rates were calculated from available clinical data. Survival outcomes were determined using the Kaplan Meier method. RESULTS: Fifty-six patients met our selection criteria. The two-year local control rate was 84.2%. The two and 5-year disease-free survival (DFS) and OS were 31.9% and 15.3% and 39.9% and 12.1%, respectively. Centroid BED10 > 150Gy was associated with improved DFS, (p = 0.014), and OS on univariable analysis (p=0.0132). CONCLUSIONS: SBRT provides good local control for T2N0 NSCLC, but systemic failure remains problematic.

Proton Beam Therapy in the Treatment of Periorbital Malignancies.

PURPOSE: Periorbital tumor location presents a significant challenge with 3-dimensional conformal radiation therapy or intensity modulated radiation therapy due to high tumor dose needed in the setting of close proximity to orbital structures with lower tolerance. Proton beam therapy (PBT) is felt to be an effective modality in such cases due to its sharp dose gradient. MATERIALS AND METHODS: We reviewed our institutional PBT registry and identified 17 patients with tumor epicenters within 2 cm of the eye and optic apparatus treated with passive scatter PBT with comparison volumetric arc therapy plans available. Maximum and mean doses to organs at risk of interest, including optic nerves, optic chiasm, lens, eye ball, pituitary, cochlea, lacrimal gland, and surrounding brain, were compared using the paired Wilcoxon signed rank test. Overall survival was determined using the Kaplan-Meier method. RESULTS: Median age was 67. Median follow-up was 19.7 months. Fourteen patients underwent upfront resection and received postoperative radiation and 3 received definitive radiation. One patient received elective neck radiation, 2 underwent reirradiation, and 3 had concurrent chemotherapy. There was a statistically significant reduction in mean dose to the optic nerves and chiasm, brain, pituitary gland, lacrimal glands, and cochlea as well as in the maximum dose to the optic nerves and chiasm, pituitary gland, lacrimal glands, and cochlea with PBT. The 18-month cumulative incidence of local failure was 19.1% and 1-year overall survival was 80.9%. CONCLUSION: Proton beam therapy resulted in significant dose reductions to several periorbital and optic structures compared with volumetric arc therapy. Proton beam therapy appears to be the optimal radiation modality in such cases to minimize risk of toxicity to periorbital organs at risk.

Reirradiation for Recurrent Scalp Angiosarcoma: Dosimetric Advantage of PBT over VMAT and EBT.

PURPOSE: Reirradiation in the scalp area can be challenging given the proximity to organs at risk (OARs), such as the eye and brain. Our aim is to evaluate the dosimetric differences of volumetric modulated arc therapy (VMAT) and electron beam therapy (EBT) compared with 3-dimensional proton beam therapy (PBT). PATIENTS AND METHODS: We evaluated a patient with recurrent angiosarcoma of the left temporal scalp after prior surgical resections and radiation therapy to 60 Gy in 30 fractions who needed reirradiation. We generated VMAT, EBT, and PBT plans using the Pinnacle Treatment Planning System (TPS). Both VMAT and EBT plans used a skin bolus, whereas no bolus was used for the proton plan. Doses to the OARs, including cochlea, eyes, lens, lacrimal glands, optic nerves, optic chiasm, pituitary gland, and underlying brain, were compared. RESULTS: The reirradiation treatment dose was 60 Gy(RBE). Target volume coverage was comparable in all plans. Compared with VMAT and EBT, the PBT plan showed reductions in mean and maximum doses to all OARs. Without the use of protons, several OARs would have exceeded dose tolerance utilizing VMAT or electrons. Dose reduction of up to 100% was achieved for central and contralateral OARs. CONCLUSION: Compared with VMAT and EBT, PBT resulted in dose reductions to all OARs, while maintaining excellent target coverage. PBT showed a significant advantage in treating superficially located skin cancers, such as angiosarcoma, without the need for a bolus. PBT can be considered in the upfront treatment and certainly in the reirradiation setting.

Three or More Courses of Stereotactic Radiosurgery for Patients with Multiply Recurrent Brain Metastases.

BACKGROUND: Although patients with brain metastasis are treated with primary stereotactic radiosurgery (SRS), the use of salvage therapies and their consequence remains understudied. OBJECTIVE: To study the intracranial recurrence patterns and salvage therapies for patients who underwent multiple SRS courses. METHODS: A retrospective review was performed of 59 patients with brain metastases who underwent ≥3 SRS courses for new lesions. Cox regression analyzed factors predictive for overall survival. RESULTS: The median age at diagnosis was 52 years. Over time, patients underwent a median of 3 courses of SRS (range: 3-8) to a total of 765 different brain metastases. The 6-month risk of distant intracranial recurrence after the first SRS treatment was 64% (95% confidence interval: 52%-77%). Overall survival was 40% (95% confidence interval: 28%-53%) at 24 months. Only 24 patients (41%) had a decline in their Karnofsky Performance Status ≤70 at last office visit. Quality of life was preserved among 77% of patients at 12 months, with 45% experiencing clinically significant improvement during clinical follow-up. Radiation necrosis developed in 10 patients (17%). On multivariate analysis, gender (males, Hazard Ratio [HR]: 2.0, P < .05), Karnofsky Performance Status ≤80 (HR 3.2, P < .001), extracranial metastases (HR: 3.6, P < .001), and a distant intracranial recurrence ≤3 months from initial to repeat SRS (HR: 3.8, P < .001) were associated with a poorer survival. CONCLUSION: In selected patients, performing ≥3 SRS courses controls intracranial disease. Patients may need salvage SRS for distant intracranial relapse, but focal retreatments are associated with modest toxicity, do not appear to negatively affect a patient's performance status, and help preserve quality of life.

Responses to the McGill Pain Questionnaire predict neuropathic pain medication use in women in with vulvar lichen sclerosus.

OBJECTIVE: The goal of this study was to test the hypothesis that responses to the McGill Pain Questionnaire are predictive of adjunctive neuropathic pain medication use by women with lichen sclerosus (LS). MATERIALS AND METHODS: This is a retrospective chart review of 430 women with vulvar LS treated at a tertiary referral vulvar care clinic. Demographics, responses to the McGill Pain Questionnaire, and use of neuropathic pain medications were collected. Bivariate and multivariable logistic regression analyses were performed to identify factors significantly associated with use of neuropathic pain medications. RESULTS: Of the 430 subjects, 119 (27.7%) used neuropathic pain medications for vulvar pain. Factors significantly associated with use of these medications include lower body mass index (odds ratio [OR] = 0.96, p = .02), non-White race (OR = 2.97, p = .05), and total McGill Pain Questionnaire score (OR = 1.05, p < .001). CONCLUSIONS: Vulvar pain is a common presenting symptom in women with LS. Responses to the McGill Pain Questionnaire may be helpful in the long-term management of women with LS as a screen to identify those patients who might benefit from adjunctive neuropathic pain medication use.

Rates of self-reported urinary, gastrointestinal, and pain comorbidities in women with vulvar lichen sclerosus.

OBJECTIVE: The study aimed to determine the prevalences of comorbid disorders in women with vulvar lichen sclerosus. MATERIALS AND METHODS: A retrospective review of self-administered questionnaires regarding the health history of 308 women with lichen sclerosus seen at a vulvar clinic between 2006 and 2011 was performed. Responses to questions about urinary (overactive bladder [OAB], urinary incontinence [UI], and stress UI), gastrointestinal (inflammatory bowel diseases, constipation, and irritable bowel syndrome), thyroid dysfunction and pain (interstitial cystitis, fibromyalgia, temporomandibular joint disorder, and vulvar pain) disorders were collected. The percentage of subjects self-reporting each comorbidity was compared with the published prevalence in the general population using a single-value binomial test. RESULTS: Subject demographics (data presented as median [range] or percentage): age, 56.4 years (20.0-92.5); body mass index, 27.5 kg/m2 (17.4-53.1); parity 2 (0-10); white, 92.9%; and biopsy proven 65.6%. Prevalences of self-reported comorbidities in our subjects are as follows: OAB, 15.3%; UI, 38.6%; stress UI, 27.9%; inflammatory bowel diseases, 1.9%; constipation, 32.5%; irritable bowel syndrome, 19.5%; thyroid dysfunction, 33.1%; interstitial cystitis, 2.6%; fibromyalgia, 9.1%; temporomandibular joint disorder, 13.0%; and vulvar pain, 83.1%. The prevalence of each disorder is significantly different from that in the general population, with all p values ≤ .02. CONCLUSIONS: Vulvar lichen sclerosus is associated with numerous bladder, bowel, and pain comorbidities. The prevalences of all of these disorders are higher in our subjects than the general population except OAB, which we find at approximately one third of the general population. Patients with lichen sclerosus should be screened for comorbidities that may affect their health and/or quality of life.