Financial Toxicity in Swiss Cancer Patients Treated with Proton Therapy: An Observational Cross-Sectional Study on Self-Reported Outcome.

BACKGROUND: Proton therapy is indicated for cancers that would be difficult to treat with conventional radiotherapy. Compulsory healthcare insurance covers the costs of this therapy in Switzerland, but this does not mean that proton therapy is cost-neutral for every cancer patient. Significant out-of-pocket (OOP) costs may arise due to expenses associated with proton therapy, and patients may experience treatment-related financial distress-an effect known as "financial toxicity." This study investigates the financial toxicity of patients undergoing proton therapy in a high-income country with a compulsory health insurance policy. METHODS: Between September 2019 and November 2021, 146 Swiss cancer patients treated with proton therapy participated in this study, of whom 90 (62%) were adults and 56 (38%) were caregivers of child cancer patients. Financial toxicity was assessed using the FACIT Comprehensive Score for Financial Toxicity (COST). OOP costs during proton therapy were recorded weekly, and financial coping strategies were captured at the end of treatment. FINDINGS: The median COST score, indicating financial toxicity, was 29.9 (IQR 21.0; 36.0) for all patients, 30.0 (IQR 21.3; 37.9) for adults, and 28.0 (IQR 20.5; 34.0) for children's caregivers. Higher income (estimate 8.1, 95% CI 3.7 to 12.4, p ≤ 0.001) was significantly associated with higher COST scores, indicating less financial toxicity. Further distance from home to the treatment centre per 100 km (estimate -3.7, 95% CI -5.7 to -1.9, p ≤ 0.001) was significantly associated with lower COST scores, indicating increased financial toxicity. Married adult patients had substantially lower COST scores than single patients (estimate: -9.1, 95% CI -14.8 to -3.4, p ≤ 0.001). The median OOP cost was 2050 Swiss francs (CHF) and was spent mainly on travel, accommodation, and eating out. Sixty-three (43%) patients used their savings; 54 (37%) cut spending on leisure activities; 21 (14.4%) cut living expenses; 14 (9.6%) borrowed money; nine (6.2%) worked more; and four (2.7%) sold property. Patients with high COST scores used significantly fewer coping strategies such as saving on leisure activities (estimate -9.5, 95% CI -12.4 to -6.6, p ≤ 0.001), spending savings (estimate -3.9, 95% CI -6.3 to -1.4, p = 0.002), borrowing money (estimate -6.3, 95% CI -10.4 to -2.2, p = 0.003), and increasing workload (estimate -5.5, 95% CI -10.5 to -0.4, p = 0.035). INTERPRETATION: A substantial number of cancer patients treated with proton therapy experience financial toxicity in Switzerland. Long travel distances to the proton therapy centre and low income negatively affect the financial well-being of these patients during proton therapy.

Management of Prostate Cancer with Systemic Therapy: A Prostate Cancer Unit Perspective.

The scenario of systemic therapy for prostate cancer is rapidly evolving, with new drugs and new treatment options. To update the background knowledge of shared uro-oncologic practice, we reviewed current statements and landmarks in systemic therapy. A number of new agents are under investigation in non-metastatic and metastatic disease. Similarly, new target imaging technologies are under development to improve the detection rate of true non-metastatic and true metastatic patient. Five new drugs have shown to be effective on progression-free and overall survival in metastatìc prostate cancer. However, the optimal sequencing of these treatments requires further investigation. The tolerability and side effects of the new drugs are also crucial issues to be discussed, as well as their activity against the disease. The uro-oncologic team has to stay updated about new medical therapies in order to be confident in debating with other professionals involved in prostate cancer decision making. Different points of view and nuances should be shared during multidisciplinary group discussions to achieve a balanced decision in disease management.

Value of fused 18F-Choline-PET/MRI to evaluate prostate cancer relapse in patients showing biochemical recurrence after EBRT: preliminary results.

PURPOSE: We compared the accuracy of (18)F-Choline-PET/MRI with that of multiparametric MRI (mMRI), (18)F-Choline-PET/CT, (18)F-Fluoride-PET/CT, and contrast-enhanced CT (CeCT) in detecting relapse in patients with suspected relapse of prostate cancer (PC) after external beam radiotherapy (EBRT). We assessed the association between standard uptake value (SUV) and apparent diffusion coefficient (ADC). METHODS: We evaluated 21 patients with biochemical relapse after EBRT. Patients underwent (18)F-Choline-PET/contrast-enhanced (Ce)CT, (18)F-Fluoride-PET/CT, and mMRI. Imaging coregistration of PET and mMRI was performed. RESULTS: (18)F-Choline-PET/MRI was positive in 18/21 patients, with a detection rate (DR) of 86%. DRs of (18)F-Choline-PET/CT, CeCT, and mMRI were 76%, 43%, and 81%, respectively. In terms of DR the only significant difference was between (18)F-Choline-PET/MRI and CeCT. On lesion-based analysis, the accuracy of (18)F-Choline-PET/MRI, (18)F-Choline-PET/CT, CeCT, and mMRI was 99%, 95%, 70%, and 85%, respectively. Accuracy, sensitivity, and NPV of (18)F-Choline-PET/MRI were significantly higher than those of both mMRI and CeCT. On whole-body assessment of bone metastases, the sensitivity of (18)F-Choline-PET/CT and (18)F-Fluoride-PET/CT was significantly higher than that of CeCT. Regarding local and lymph node relapse, we found a significant inverse correlation between ADC and SUV-max. CONCLUSION: (18)F-Choline-PET/MRI is a promising technique in detecting PC relapse.

Analysis of NADP+-dependent isocitrate dehydrogenase-1/2 gene mutations in pediatric brain tumors: report of a secondary anaplastic astrocytoma carrying the IDH1 mutation.

Somatic mutations of the isocitrate dehydrogenase-1 gene (IDH1), most commonly resulting in replacement of arginine at position 132 by histidine (p.R132H), have been reported for WHO grade II and III diffuse gliomas and secondary glioblastomas. We investigated IDH1/2 mutations in a retrospective series of 165 pediatric brain tumors, including atypical teratoid/rhabdoid tumors (AT/RT) and choroid plexus tumors, which had not previously been investigated. Mutation analysis was performed by use of pyrosequencing and, additionally, data were validated for a cohort of 70 gliomas from among the series by use of the arrayed primer extension technique. We identified one tumor which harbored mutation of IDH1 at codon 132 and no alteration was identified in the matched-germline DNA. No IDH2 mutations were detected. Most noteworthy, the IDH1 mutant tumor was an anaplastic astrocytoma involving the cortex in the left frontal lobe which appeared seven years after radiation treatment for an extensive sellar/suprasellar craniopharyngioma. This anaplastic astrocytoma was regarded as secondary to radiation treatment because it seemed to originate within the irradiation field that received a dose varying from a maximum of 30.6 Gy of 4 MV X-rays down to very few Gy of lower-energy scattered radiation. In this work our observations agree with those in previous reports showing the rarity of IDH1/2 mutations in childhood tumors. The interesting identification of an IDH1 mutation in a radiation-induced secondary malignant glioma raises the likelihood that these types of tumor may develop IDH1/2 mutations. Thus, caution is needed when dealing with these tumors, and further genetic analysis is warranted.

Locally advanced rectal cancer patients receiving radio-chemotherapy: a novel clinical-pathologic score correlates with global outcome.

PURPOSE: To determine the importance of downstaging of locally advanced rectal cancer after neoadjuvant treatment. METHODS AND MATERIALS: The study included all consecutive patients with locally advanced rectal cancer who underwent neoadjuvant treatment (chemotherapy and/or radiotherapy) in different Italian centers from June 1996 to December 2003. A novel score was used, calculated as the sum of numbers obtained by giving a negative or positive point, respectively, to each degree of increase or decrease in clinical to pathologic T and N status. RESULTS: A total of 317 patients were eligible for analysis. Neoadjuvant treatments performed were as follows: radiotherapy alone in 75 of 317 patients (23.7%), radiotherapy plus chemotherapy in 242 of 317 patients (76.3%). Worse disease-free survival was observed in patients with a lower score (Score 1 = -3 to +3 vs. Score 2 = +4 to +7; p = 0.04). CONCLUSIONS: Our results suggest that a novel score, calculated from preoperative and pathologic tumor and lymph node status, could represent an important parameter to predict outcome in patients receiving neoadjuvant treatment for rectal cancer. The score could be useful to select patients for adjuvant chemotherapy after neoadjuvant treatment and surgery.

Mucinous rectal adenocarcinoma can be associated to tumor downstaging after preoperative chemoradiotherapy.

PURPOSE: The aim of this study was to evaluate downstaging as primary end point, and progression-free survival and overall survival as secondary end points, in rectal adenocarcinoma patients treated with preoperative chemoradiation. METHODS: One hundred and thirty-six extraperitoneal adenocarcinoma patients (33 low rectum T2, 74 T3, 29 T4 [without sacral invasion], 25 with mucinous subtype) were treated with posterior pelvis preoperative radiotherapy (5040 cGy total dose, 180 cGy/fr, 5 fr/w, 10-15 MV linac X-rays) and concomitant 5-fluorouracil-based chemotherapy. After 6 to 8 weeks patients underwent surgery and prechemoradiation clinical stage was compared with pathologic stage to evaluate downstaging in each patient. Seventy-four patients received adjuvant chemotherapy. Median follow-up was 39 months (4-84). RESULTS: Forty-four patients had macroscopic complete response, 52 patients had partial response, 37 patients showed no change and 3 patients had progression. At multivariate analysis only histotype showed correlation with downstaging (hazard ratio = 0.350 and 0.138 - 0.885 95 percent confidence interval) because of the evidence for poor downstaging in mucinous subtype. There were no significant differences in overall survival and progression-free survival between adenocarcinoma and mucinous subtype. CONCLUSIONS: The main finding is that mucinous histology is associated with poor downstaging after preoperative chemoradiation but this poor response was not associated with worse outcome in this small study. The good outcome for mucinous histology is at odds with other reports in the literature and requires further study.

Is one Gy equal to one Gy after treatment interruptions?

The problem of radiotherapy treatment interruptions has been addressed taking into account the linear quadratic model. Simple treatment interruption recovery is possible by using the Biological Effective Dose equivalence between the initially planned total dose and the increased actual total dose. The supplement dose necessary to compensate for tissue proliferation during interruption, is to be considered. This is possible only for acute responding tissue with large alfa/beta ratio as tumors, epithelium, mucosa. However, a higher total dose planned for treatment interruption recovery may overcome late responding vascular and connective tissue or spinal cord tolerance where tissue proliferation is stimulated only after very long latent periods, well beyond the end of even prolonged treatments. Models of dose fractionation or hyperfractionation for recovery of tumor effect not exceeding the late responding tissue tolerance, can be devised by compromising between the planned and modified Biological Effective Dose both in acute and late response tissue.

Down-staging after two different preoperative chemoradiation schedules in rectal cancer.

AIMS: To compare preoperative down-staging, toxicity and sphincter-saving procedures obtained with preoperative radiotherapy and two different concomitant chemotherapy schedules. METHODS: From February 1997 to August 2001, 68 consecutive patients were treated with external radiotherapy (5040 cGy in 28 fractions) and concomitant chemotherapy: group a) 36 patients (10 T2, 19 T3, 7 T4, 25 adenocarcinoma and 11 mucinous histology) were treated with cis-diamminedichloroplatinum bolus + 5-fluorouracil continuous infusion; group b) 32 patients (14 T2, 18 T3, 27 adenocarcinoma and 5 mucinous histology) were treated with 5-fluorouracil bolus +/- mitomycin C. The interval between the end of radiotherapy and surgery ranged from 4 to 9 weeks. RESULTS: Group a) Overall down-staging was 63.9%. Longitudinal shrinkage of the neoplasm allowed conservative surgery in 6 of 11 patients with a pre-chemoradiation tumor location < or = 3 cm from the external anal ring. When patients with adenocarcinoma (25/36) were studied separately from patients with mucinous histology, 7/25 patients (28%) were found to have no microscopic evidence of residual tumor (pT0); 8/25 (32%) were found to have only rare isolated cancer cells (pTmic); only 7/25 patients (28%) were found to have no change. Overall, 72% patients had down-staging. In contrast, only 5/11 (45.5%) of mucinous tumors had partial down-staging and 6/11 (54.5%) no down-staging at all. Group b) Overall down-staging was 46.9%. When patients with adenocarcinoma (27/32) were studied separately, 7/27 (26%) were found to have pT0, 3/27 (11.1%) pTmic, and 13/27 (48.1%) no change. Only 1/5 (20%) of mucinous tumors had down-staging and 4/5 (80%) had no down-staging at all. Overall toxicity was comparable among groups a and b, except for lower hematologic and gastrointestinal G3-4 toxicity observed in group a. CONCLUSIONS: The overall response allowed conservative surgery in 56 (82.3%) of the 68 patients. Continuous infusion of 5-fluorouracil and diamminedichloroplatinum as a radiosensitizer determined better results in group a than group b (63.9% down-staging vs 46.9% even with a higher incidence of mucinous histology). Mucinous histology, for a definitely lower response rate, could benefit from an even more aggressive approach.