Consensus Statement Supporting the Presence of Onsite Radiation Oncology Departments at VHA Medical Centers.

Background: Although multiple studies demonstrate that radiotherapy is underused worldwide, the impact that onsite radiation oncology at medical centers has on the use of radiotherapy is poorly studied. The Veterans Health Administration (VHA) Palliative Radiotherapy Taskforce has evaluated the impact of onsite radiation therapy on the use of palliative radiation and has made recommendations based on these findings. Observations: Radiation consults and treatment occur in a more timely manner at VHA centers with onsite radiation therapy compared with VHA centers without onsite radiation oncology. Referring practitioners with onsite radiation oncology less frequently report difficulty contacting a radiation oncologist (0% vs 20%, respectively; P = .006) and patient travel (28% vs 71%, respectively; P < .001) as barriers to referral for palliative radiotherapy. Facilities with onsite radiation oncology are more likely to have multidisciplinary tumor boards (31% vs 3%, respectively; P = .11) and are more likely to be influenced by radiation oncology recommendations at tumor boards (69% vs 44%, respectively; P = .02). Conclusions: The VHA Palliative Radiotherapy Taskforce recommends the optimization of the use of radiotherapy within the VHA. Radiation oncology services should be maintained where present in the VHA, with consideration for expansion of services to additional facilities. Telehealth should be used to expedite consults and treatment. Hypofractionation should be used, when appropriate, to ease travel burden. Options for transportation services and onsite housing or hospitalization should be understood by treating physicians and offered to patients to mitigate barriers related to travel.

Skull Base Regeneration During Treatment With Chemoradiation for Nasopharyngeal Carcinoma: A Case Report.

Background: Advanced cases of nasopharyngal carcinoma can present with skull base invasion. Treatment of these advanced cases with radiotherapy poses a challenge given proximity of tumor to critical neural structures as well as concern that a skull base defect and associated complications could develop with tumor regression. Case Presentation: A 34-year-old male patient presented with a 7-cm nasopharyngeal tumor invading the skull base with destruction of the clivus and intracranial extension. He underwent a course of definitive chemoradiation, requiring use of adaptive radiotherapy, that resulted in complete tumor regression and is free of disease 5 years posttreatment. Imaging done during treatment demonstrated that significant regeneration of bone occurred simultaneously with tumor regression. Conclusions: This case demonstrates that it is possible for bony regeneration to occur simultaneously with tumor regression in a patient with skull base invasion by tumor, precluding the need for neurosurgical intervention.

Palliative Radiotherapy Within the Veterans Health Administration: Barriers to Referral and Timeliness of Treatment.

PURPOSE: Most Veterans Health Administration hospitals do not have radiation oncology (RO) departments on-site. The purpose of this study is to determine the impact of on-site RO on referral patterns and timeliness of palliative radiation therapy (PRT). MATERIALS AND METHODS: A survey was sent to medical directors at 149 Veterans Health Administration centers. Questions evaluated frequency of referral for PRT, timeliness of RO consults and treatment, and barriers to referral for PRT. Chi-square analysis was used to evaluate differences between centers that have on-site RO and centers that refer to outside facilities. RESULTS: Of 108 respondents, 33 (31%) have on-site RO. Chi-square analysis revealed that RO consult within 1 week is more likely at centers with on-site RO (68% v 31%; P = .01). Centers with on-site RO more frequently deliver PRT for spinal cord compression within 24 hours (94% v 70%; P = .01). Those without on-site RO were more likely to want increased radiation oncologist involvement (64% v 26%; P < .001). Barriers to referral for PRT included patient ability to travel (81%), patient noncompliance (31%), delays in consult and/or treatment (31%), difficulty contacting a radiation oncologist (14%), and concern regarding excessive number of treatments (13%). Respondents with on-site RO less frequently reported delays in consult and/or treatment (6% v 41%; P < .0001) and difficulty contacting a radiation oncologist (0% v 20%; P = .0056) as barriers. CONCLUSION: Respondents with on-site RO reported improved communication with radiation oncologists and more timely consultation and treatment initiation. Methods to improve timeliness of PRT for veterans at centers without on-site RO should be considered.

Radiotherapeutic Care of Patients With Stage IV Lung Cancer with Thoracic Symptoms in the Veterans Health Administration.

BACKGROUND: Radiotherapy plays an important role in the palliation of lung cancer, which is the second most common cancer diagnosed in the Veterans Health Administration (VHA). The American Society for Radiation Oncology (ASTRO) developed evidenced-based treatment guidelines for the management of patients with metastatic lung cancer. METHODS: In May 2016, an electronic survey of 88 VHA radiation oncologists (ROs) was conducted to assess metastatic lung cancer management. Demographic information was obtained and 2 clinical scenarios were presented to glean opinions on dose/fractionation schemes preferred, preferences for/against concurrent chemotherapy, and use of endobronchial brachytherapy (EBB) and/or yttrium aluminum garnet (YAG) laser technology. Survey results were assessed for concordance with published ASTRO guidelines. RESULTS: The survey response rate was 61%, with 93% of the 40 VHA radiation departments represented. Among respondents, 96% were board certified, and 90% held academic appointments. 88% were familiar with ASTRO guidelines. Preferred fractionation schemes were 20 Gy in 5 fractions (69%) and 30 Gy in 10 fractions (22%). The vast majority (98%) did not recommend concurrent chemotherapy for palliation. In the setting of bronchial obstruction with lung collapse, about half (49%) recommended EBB or YAG lung reexpansion before external beam radiotherapy. A minority of respondents use stereotactic body radiotherapy or EBB for palliation. CONCLUSION: Most respondents demonstrated up-to-date knowledge of current evidence-based treatment guidelines. We found no distinction in clinical decisions based on demographic profiles.

Management of metastatic spinal cord compression among Veterans Health Administration radiation oncologists.

BACKGROUND: Optimal management of metastatic spinal cord compression (MSCC) improves functional outcomes in patients with metastatic disease. This survey study evaluated management of MSCC by Veterans Health Administration (VHA) radiation oncologists (ROs), to determine whether management of MSCC correlates with American College of Radiology (ACR) guidelines, and to compare times to initiation of treatment between surgery and radiotherapy (RT). METHODS: Surveys emailed to 79 VHA ROs included questions on steroid use, surgical care, palliative care, fractionation of irradiation, re-irradiation, and management of common MSCC case scenarios. Follow-up phone calls were made to encourage survey participation. Descriptive statistics and chi-square testing were done to show significant associations. RESULTS: The survey yielded an 81.0% response rate; 79.4% of ROs had read the ACR Appropriateness Criteria® Spinal Bone Metastases. The majority (87.3%) prefer 30 Gy/10 fractions for MSCC, and all respondents recommend steroid therapy in conjunction with RT. When used, RT was more often initiated within 24 hours than was neurosurgery (83.9% vs. 34.5%, P<0.001). All ROs report use of palliative care services. Re-irradiation is given by 66.1%: 30.7% with stereotactic body radiation therapy (SBRT), 17.7% using intensity modulated radiation therapy (IMRT), and 17.7% using conventional RT. For the case scenarios, most respondents' (>75%) management concurred with ACR guidelines. CONCLUSIONS: The majority of VHA ROs are familiar with the ACR Appropriateness Criteria® Spinal Bone Metastases and practice accordingly. Treatment within 24 hours is more likely when RT is the primary modality compared to when surgical decompression precedes RT.

Palliative Radiotherapy for the Management of Metastatic Cancer: Bone Metastases, Spinal Cord Compression, and Brain Metastases.

Life expectancy and tumor characteristics should be considered when making treatment recommendations for palliative radiotherapy, which can be cost-effective and provide symptom relief.

The role of radiotherapy in locally advanced pancreatic carcinoma.

The prognosis for locally advanced pancreatic carcinoma remains dismal despite advances in chemotherapy and radiotherapy over the past few decades. The use of radiotherapy for pancreatic carcinoma is often disputed because of the hypothesis that patients with pancreatic cancer die from distant metastases. It is well accepted that the greatest chance for cure of pancreatic cancer involves surgical resection of the primary tumor. However, there is much controversy about the role of radiotherapy in local disease control. The aim of this Review is to discuss data from the available studies, both prospective and retrospective, that evaluate treatment options for locally advanced pancreatic cancer. We focus on the benefits associated with local therapies, including radiotherapy and surgical resection, as they relate to improved local disease control, prolonged overall survival and improved symptom control.

Statin use and risk of prostate cancer recurrence in men treated with radiation therapy.

PURPOSE: There has been growing interest in the potential anticancer activity of statins based on preclinical evidence of their antiproliferative, proapoptotic, and radiosensitizing properties. The primary objective of this study was to determine whether statin use is associated with improved clinical outcomes in patients treated with radiotherapy (RT) for prostate cancer. PATIENTS AND METHODS: In total, 691 men with prostate adenocarcinoma treated with curative-intent RT between 1988 and 2006 were retrospectively analyzed. Of those, 189 patients (27%) were using statins, either during initial consultation or during follow-up. Lipid panels were collected (n = 298) a median of 5 months before RT start. Median follow-up was 50 months after RT. RESULTS: Statin use was associated with improved freedom from biochemical failure (FFBF; P < .001), freedom from salvage androgen deprivation therapy (FFADT; P = .0011), and relapse-free survival (RFS; P < .001). Improved FFBF for statin users was seen in low-, intermediate-, and high-risk groups (P = .0401, P = .0331, and P = .0034, respectively). The improvement in FFBF with statin use was independent of ADT use or radiation dose. On multivariable analysis, statin use was associated with improved FFBF (P < .001) along with pretreatment prostate-specific antigen < or = 8.4 (P < .001), stage less than T2b (P = .0111), and Gleason score < 7 (P = .0098). On univariate analysis, pretreatment total cholesterol < 187 (89% v 80%; P = .0494) and low-density lipoprotein (LDL) < 110 (96% v 85%; P = .0462) were associated with improved 4-year FFBF. CONCLUSION: Statin use was associated with a significant improvement in FFBF, FFADT, and RFS in this cohort of men treated with RT for prostate cancer. The favorable effect of statins may be mediated by direct effect or via the LDL-lowering effect of these medications.

Adjuvant radiotherapy for resected pancreatic cancer: a lack of benefit or a lack of adequate trials?

Surgical resection is the most effective means of controlling nonmetastatic pancreatic cancer, but recurrence rates are high even after complete resection. For several types of tumor of the gastrointestinal tract, combined modality therapy that includes radiation therapy has been shown to reduce the recurrence rate and improve disease-free survival. The use of adjuvant radiotherapy for pancreatic cancer, however, is controversial. Results of the few randomized trials of adjuvant radiotherapy for pancreatic cancer are conflicting. In addition, as pancreatic cancer is associated with high rates of distant recurrence, the additional benefit provided by local therapy has been perceived as questionable. This article reviews the studies--prospective and retrospective--of adjuvant radiotherapy for pancreatic cancer and the issues surrounding the use of this strategy.

Cardiac morbidity and mortality after breast conservation treatment in patients with early-stage breast cancer and preexisting cardiac disease.

BACKGROUND: This study was undertaken to determine the risk of late cardiac morbidity and mortality in patients with preexisting cardiac disease treated with contemporary radiation techniques for early-stage breast cancer. PATIENTS AND METHODS: Medical records were reviewed for 41 patients with early-stage breast cancer and a history of myocardial infarction, congestive heart failure (CHF), and/or coronary artery disease before radiation therapy. Data were recorded on baseline cardiac disease and tumor characteristics, cardiac morbidity during and after treatment, and survival status of each patient. Patients were stratified for right- versus left-sided breast cancer and compared. RESULTS: There was no significant difference in overall survival (OS) between the right- and left-sided groups (log-rank test; P = .19). The left-sided group had a higher incidence of cardiac deaths (right side, 2 of 26 [9%]; left side, 4 of 15 [27%]; hazard ratio, 4.2; P = .08) 10 years after treatment, including deaths secondary to myocardial infarction, CHF, or coronary artery disease. On the other hand, the right-sided group had a higher proportion of deaths secondary to breast cancer (right, 8 of 26 [31%]; left, 2 of 15 [13%]) and non-breast cancer/noncardiac causes (right, 7 of 26 [27%]; left, 1 of 15 [7%]). CONCLUSION: Although OS was similar in both groups, radiation was associated with a higher incidence of cardiac death in patients with left-sided breast cancer. Efforts should be made to minimize cardiac exposure and also to promote more vigilant risk factor modification in this group of women.