Precision Population Cancer Medicine in Cancer of the Uterine Cervix: A Potential Roadmap to Eradicate Cervical Cancer.

With the success of the Human Genome Project, the era of genomic medicine (GM) was born. Later on, as GM made progress, there was a feeling of exhilaration that GM could help resolve many disease processes. It also led to the conviction that personalized medicine was possible, and a relatively synonymous word, precision medicine (PM), was coined. However, the influence of environmental factors and social determinants of diseases was only partially given their due importance in the definition of PM, although more recently, this has been recognized. With the rapid advances in GM, big data, data mining, wearable devices for health monitoring, telemedicine, etc., PM can be more easily extended to population-level health care in disease management, prevention, early screening, and so on.and the term precision population medicine (PPM) more aptly describes it. PPM's potential in cancer care was posited earlier,and the current authors planned a series of cancer disease-specific follow-up articles. These papers are mainly aimed at helping emerging students in health sciences (medicine, pharmacy, nursing, dentistry, public health, population health), healthcare management (health-focused business administration, nonprofit administration, public institutional administration, etc.), and policy-making (e.g., political science), although not exclusively. This first disease-specific report focuses on the cancer of the uterine cervix (CC). It describes how recent breakthroughs can be leveraged as force multipliers to improve outcomes in CC - by improving early detection, better screening for CC, potential GM-based interventions during the stage of persistent Human papillomavirus (HPV) infection and treatment interventions - especially among the disadvantaged and resource-scarce populations. This work is a tiny step in our attempts to improve outcomes in CC and ultimately eradicate CC from the face of the earth.

Eye Plaque Brachytherapy for Choroidal Malignant Melanoma: A Case Report on the Use of Innovative Technology to Expand Access, Improve Practice, and Enhance Outcomes.

Our institute established an eye plaque interstitial brachytherapy (EPIBT) program in 2007 using the Collaborative Ocular Melanoma Study (COMS) eye plaque. In this case report, we demonstrated an eye plaque treatment planned and executed using Eye Physics Plaque (Los Alamitos, CA) for a 72-year-old male patient with an extra-large tumor with a maximum width of 18.6 mm and height of 13.7 mm. The use of a customized eye plaque, manufactured through three-dimensional (3D) printing, has empowered us to plan and administer treatment for this patient with uveal melanoma. Without this option, enucleation, an option declined by the patient, or proton beam therapy (PBT), which the patient was unwilling to pursue in another state, would have been the alternative course of action. We were able to use more than one activity of the I-125 seeds, which enabled us to shape and reduce the dose to normal surrounding structures at risk within the orbit and in the vicinity of the orbital cavity. Using the dose evaluation tools available with the modern treatment planning system, we reduced the prescription dose from 85 to 70 Gy, with D90 of 140 Gy, thereby providing effective treatment and limiting risk organ doses. In summary, we were able to dose-deescalate without compromising the chances of controlling retinal/scleral tumors. The patient is doing well from a recent follow-up visit 12 months after the eye plaque brachytherapy treatment. The tumor was 4.80 mm high, 1/3 of the original height, and vision is back to 20/60, demonstrating a successful treatment.

An Overview of the Use of Precision Population Medicine in Cancer Care: First of a Series.

Advances in science and technology in the past century and a half have helped improve disease management, prevention, and early diagnosis and better health maintenance. These have led to a longer life expectancy in most developed and middle-income countries. However, resource- and infrastructure-scarce countries and populations have not enjoyed these benefits. Furthermore, in every society, including in developed nations, the lag time from new advances, either in the laboratory or from clinical trials, to using those findings in day-to-day medical practice often takes many years and sometimes close to or longer than a decade. A similar trend is seen in the application of "precision medicine" (PM) in terms of improving population health (PH). One of the reasons for such lack of application of precision medicine in population health is the misunderstanding of equating precision medicine with genomic medicine (GM) as if they are the same. Precision medicine needs to be recognized as encompassing genomic medicine in addition to other new developments such as big data analytics, electronic health records (EHR), telemedicine, and information communication technology. By leveraging these new developments together and applying well-tested epidemiological concepts, it can be posited that population/public health can be improved. In this paper, we take cancer as an example of the benefits of recognizing the potential of precision medicine in applying it to population/public health. Breast cancer and cervical cancer are taken as examples to demonstrate these hypotheses. There exists significant evidence already to show the importance of recognizing "precision population medicine" (PPM) in improving cancer outcomes not only in individual patients but also for its applications in early detection and cancer screening (especially in high-risk populations) and achieving those goals in a more cost-efficient manner that can reach resource- and infrastructure-scarce societies and populations. This is the first report of a series that will focus on individual cancer sites in the future.

The Influence of Patient and System Factors on the Radiotherapy Treatment Time in the Treatment of Non-metastatic Cervical Cancer Patients in a Rural and Resource-Lean State's Safety-Net Hospital: Benefits of Strategic Planning.

Objective To decrease radiotherapy treatment time (RTT), measured from the day of initiation of radiotherapy to the day of its completion, specific strategies were initiated in early 2020 in the only academic safety-net medical center in a rural, resource-lean state. The factors that can succeed and those that need further improvements were analyzed in this initial assessment phase of our efforts to shorten the RTT. Methods This is an analysis of 28 cervix cancer patients treated with magnetic resonance imaging (MRI)-guided brachytherapy (February 2020-November 2021). The relationship between independent and dependent variable were analyzed by simple linear regression, and p-values ≤ 0.05 were considered statistically significant. SPSS software version 28.0 (IBM, Armonk, NY, USA) was used for statistical analysis. Results Two RTT groups (≤ 60 (32.1%) vs. > 60 days {67.9%}) with median RTT of 68 days (range, 51 to 106 days) were analyzed. Caucasians represented 66.7% of the RTT ≤ 60 days group. Four 'issues' were identified that increased the RTT: non-compliance, learning curve (early days of implementation of MRI-guided brachytherapy in the department), stage IV comorbidities, and with more than one issue mentioned; 77.8% with no issues had ≤ 60 days RTT vs. 26.3% for the > 60 days group. The breakdown of the no-issues factor by calendar year showed the RTT of ≤ 60 days was achieved higher in 2021 (85.7% vs. 20.0%; p=0.023) compared to 2020. For this entire cohort, the RTT of ≤ 60 days was achieved higher in 2021 (50.0% vs. 8.3%; p=0.019) compared to 2020. Data also showed improvement in RTT of ≤ 60 days for every sequential six months. 'Non-compliance' and 'learning curve' were the most important factors among patients having the longest RTTs. Conclusion The RTT can be further decreased. As a result of this preliminary analysis of the our strategic planning approach of 'circular' "See it," "Own it," "Solve it," and "Do it" and go back to the first step again, we plan to implement the following strategies in the immediate future to shorten the RTTs further and, in turn, improve our overall outcomes (local/regional control, disease-free survival, and overall survival): (a) Interdigitate MRI-guided brachytherapy during external beam radiotherapy (EBRT); patients who can not get the interdigitated brachytherapy procedures performed during the course of EBRT for any reason will receive two brachytherapy procedures per week; (c) attempt to add a cervix cancer care navigator to our staff to help patients having social issues, thus leading to compliance problems; (d) finally, in a year or two after these new strategic implementations, the RTT data will be reanalyzed.

Real World and Public Health Perspectives of Intraoperative Radiotherapy in Early-Stage Breast Cancer: A Multidisciplinary Analysis Beyond the Statistical Facts.

Breast conservation therapy (BCT) (usually a lumpectomy plus radiotherapy (RT)) has become a standard alternative to radical mastectomy in early-stage breast cancers with equal, if not higher, survival rates. The established standard of the RT component of the BCT had been about six weeks of Monday through Friday external beam RT to the whole breast (WBRT). Recent clinical trials have shown that partial breast radiation therapy (PBRT) to the region surrounding the lumpectomy cavity with shorter courses can result in equal local control, survival, and slightly improved cosmetic outcomes. Intraoperative RT (IORT) wherein RT is administered at the time of operation for BCT to the lumpectomy cavity as a single-fraction RT is also considered PBRT. The advantage of IORT is that weeks of RT are avoided. However, the role of IORT as part of BCT has been controversial. The extreme views go from "I will not recommend to anyone" to "I can recommend to all early-stage favorable patients." These divergent views are due to difficulty in interpreting the clinical trial results. There are two modalities of delivering IORT, namely, the use of low-energy 50 kV beams or electron beams. There are several retrospective, prospective, and two randomized clinical trials comparing IORT versus WBRT. Yet, the opinions are divided. In this paper, we try to bring clarity and consensus from a highly broad-based multidisciplinary team approach. The multidisciplinary team included breast surgeons, radiation oncologists, medical physicists, biostatisticians, public health experts, nurse practitioners, and medical oncologists. We show that there is a need to more carefully interpret and differentiate the data based on electron versus low-dose X-ray modalities; the randomized study results have to be extremely carefully dissected from biostatistical points of view; the importance of the involvement of patients and families in the decision making in a very transparent and informed manner needs to be emphasized; and the compromise some women may be willing to accept between 2-4% potential increase in local recurrence (as interpreted by some of the investigators in IORT randomized studies) versus mastectomy. We conclude that, ultimately, the choice should be that of women with detailed facts of the pros and cons of all options being presented to them from the angle of patient/family-focused care. Although the guidelines of various professional societies can be helpful, they are only guidelines. The participation of women in IORT clinical trials is still needed, and as genome-based and omics-based fine-tuning of prognostic fingerprints evolve, the current guidelines need to be revisited. Finally, the use of IORT can help rural, socioeconomically, and infrastructure-deprived populations and geographic regions as the convenience of single-fraction RT and the possibility of breast preservation are likely to encourage more women to choose BCT than mastectomy. This option can also likely lead to more women choosing to get screened for breast cancer, thus enabling the diagnosis of breast cancer at an earlier stage and improving the survival outcomes.

Patients and Families' Participation in Multidisciplinary Tumor Conferences Improves Patient and Family-Focused Cancer Care: Lessons Learned From a Debate on the Role of Radiation Therapy in Primary Mediastinal Non-Hodgkin Lymphoma.

Incorporation of patients' preferences often leads to improved outcomes when included in the multidisciplinary tumor conference/board (MTC). However, patients' wishes are not included or considered in the MTC decision-making. We need better strategies and approaches for patient-inclusive, shared decision-making. When finding ourselves at a crossroads regarding the next step in a patient's treatment, we saw a unique opportunity for an MTC with the patient and her husband in attendance. The results of a full literature review regarding the role of consolidative radiation therapy (RT) in a patient with primary (thymic) B-cell lymphoma after completion of chemotherapy and fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) scan with a Deauville score of 4 were presented in a creative, engaging debate-style forum with visual aids. The patient and her husband were able to follow the discussion and, in the end, a consensus recommendation, heavily focused on the patient's preferences, was offered and adopted, which ultimately resulted in the avoidance of excess treatment and likely improved her long-term quality of life outcome. These collaborative and innovative interactions benefit not only our patients but enrich our lives too as healthcare providers and strengthen us as a cancer care team in terms of understanding diversity in decision-making processes.

The Emerging Boon of Information and Communication Technology in Multidisciplinary Cancer Care: A Force Multiplier With a Human Touch.

Cancer care (CC) is incredibly complex and requires the coordination of multiple disciplines for optimal outcomes. Historically, this has been accomplished with multidisciplinary tumor boards (MDTBs), but the benefits, while perhaps intuitive, have not always been demonstrated with sufficient research robustness and validity. We hypothesize that this difficulty in demonstrating the benefit of MDTBs may be related to a delay in decision-making and operationalizing those decisions. The history and value of MDTBs are presented as well as their weaknesses and limited demonstration of improved outcomes. A major weakness highlighted by the challenges of MDTBs is the concept of total package time (TPT) (rather, the inability to keep it as short as possible); any significant delays in CC for any discipline may have a deleterious impact on any given patient's care outcome. Drawing on our own experience with utilizing information and communication technology (ICT) during an effort to apply accountability theory to improve specifically radiation therapy package time (RTPT), we argue that similar principles will be applicable in the improvement of not only the TPT which relies on multiple disciplines, but other factors of CC as well, such as coordination. Experience with improvement in RTPT is discussed and the underlying theory is demonstrated as a sound methodology to apply beyond RTPT to TPT involving coordination of multiple disciplines and stands to lead to the full realization of the benefits of the multidisciplinary approach. The complexity of cancer means that real solutions to optimal outcomes are also, by nature, complex, but here simple accountability theory is demonstrated that may unlock the next phase of multidisciplinary coordination. In this work, we argue that the benefits of the MDTB format can be fully realized with the addition of ICT, a technological breakthrough in the past two decades, while not forgetting about continued human factors.

Strategic Reduction of Package Time in Head and Neck Cancer.

Purpose: Total package time, or the time from diagnosis to completion of definitive treatment, has been associated with outcomes for a variety of tumor sites, but especially to head and neck (HN) cancer. Patients with HN cancer often undergo a complex diagnosis and treatment process involving multiple disciplines both within and outside of oncology. This complexity can lead to longer package times, and each involved discipline has the responsibility to maintain an efficient and effective process. Strategic intervention to improve package time must involve not only new technology or tools, but also "soft" components such as accountability, motivation, and leadership. This combination is necessary to truly optimize radiation therapy for HN cancer, leading to shorter total package times for these patients. Methods and Materials: Two interventions were strategically executed to improve radiation therapy workflow: upgrade of the treatment planning system and implementation of an automated patient management and accountability system. The radiation therapy-related timelines of 112 patients with HN cancer treated over 2 years were reviewed, and the average time differences were compared between the patient populations before and after the strategic interventions. Results: Purely upgrading the treatment planning system did not show significant improvements, but when combined with the patient management system, significant improvement in radiation-related package time can be noted for every time point. The overall reduction of radiation-related package time was statistically significant at 22.85 days (P = .002). Conclusions: On face value, the patient management system could be credited as responsible for the improvement, but on qualitative analysis, it is noted that the new system is only a tool that can be ignored or underused. Owing to the addition of important "soft" components such as accountability, motivation, and leadership, the patient management system was optimized and implemented in such a manner as to have the desired effect.

Changing Role of PET/CT in Cancer Care With a Focus on Radiotherapy.

Positron emission tomography (PET) integrated with computed tomography (CT) has brought revolutionary changes in improving cancer care (CC) for patients. These include improved detection of previously unrecognizable disease, ability to identify oligometastatic status enabling more aggressive treatment strategies when the disease burden is lower, its use in better defining treatment targets in radiotherapy (RT), ability to monitor treatment responses early and thus improve the ability for early interventions of non-responding tumors, and as a prognosticating tool as well as outcome predicting tool. PET/CT has enabled the emergence of new concepts such as radiobiotherapy (RBT), radioimmunotherapy, theranostics, and pharmaco-radiotherapy. This is a rapidly evolving field, and this primer is to help summarize the current status and to give an impetus to developing new ideas, clinical trials, and CC outcome improvements.

Stage Migration in Cervical Cancer Using the FIGO 2018 Staging System: A Retrospective Survival Analysis Using a Single-Institution Patient Cohort.

Introduction The International Federation of Gynecology and Obstetrics (FIGO) changed the staging system for cervical cancer in 2018 and formally allowed cross-sectional imaging for staging purposes. Stage IB is now divided into three substages based on tumor size (IB1 < 2 cm, IB2 2-4 cm and IB3 > 4 cm). The presence of lymph nodes in the pelvis or para-aortic region will upstage the patient to stage IIIC. The purpose of this study was to evaluate the extent of stage migration using the FIGO 2018 staging system for cervical cancer and validate the new staging system by assessing the survival outcomes. Methods An Institutional Review Board-approved and Health Insurance Portability and Accountability Act-compliant retrospective analysis was performed on 158 patients from the cervical cancer database at the University of Mississippi Medical Center, USA. Patients had been treated between January 2010 and December 2018, and they were all staged according to the FIGO 2009 staging system previously. We collected data regarding tumor size, lymph node presence, and extent of metastatic disease in the pretreatment CT, positron emission tomography (PET), or MRI scans and restaged the patients using the FIGO 2018 system. The extent of stage migration was evaluated using the new staging system. We analyzed the three-year overall survival (OS) using both FIGO 2009 and 2018 staging systems for validation purposes. Kaplan-Meier analyses were performed using SPSS version 24. Results Fifty-nine percent of the patients were upstaged when they were restaged using the FIGO 2018 staging system. In the current 2018 staging system, Stage IB3 accounted for 4%, and Stage IIIC accounted for 48% of the patient cohort, while other stages accounted for the rest. The median overall survival of the entire cohort was 20.5 months. There was a change in the survival curves using FIGO 2018 stages compared to those of FIGO 2009. There was a numerical improvement in three-year OS in stages IB and III among the two staging systems; however, it was not statistically significant. Interestingly, the three-year overall survival of Stage IIIC patients was better when compared to Stages III A& B combined (61% vs. 25%, p=0.017). Conclusion The increased availability of cross-sectional imaging across the world has led to recent changes in the FIGO staging system for cervical cancer, which allowed imaging in staging. We identified a significant stage migration in our patient cohort with the FIGO 2018 staging system, but no difference in the three-year overall survival was observed. Local tumor extent may be a worse prognostic indicator than nodal metastasis among stage III patients.

Initial Institutional Experience with 18F-Fluciclovine PET-CT in Biochemical Recurrence of Prostate Cancer.

OBJECTIVES: 18F-fluciclovine (fluciclovine) is an amino acid analog approved by the Food and Drug Administration for use as a radiotracer in positron emission tomography (PET) in men with biochemical recurrence of suspected prostate cancer. The purpose of this study was to investigate the initial institutional experience with 18F-fluciclovine in the evaluation of prostate cancer with biochemical recurrence. METHODS: This study was a retrospective review of 135 patients who underwent 18F-fluciclovine PET-computed tomography (PET-CT) at a single institution from August 2018 through January 2020. Prognostic information, including prostate-specific level antigen (PSA) at the time of diagnosis, initial risk, initial Gleason score, and initial stage, was reviewed as well as the PSA level at the time of the scan. The images were reviewed by two radiologists with fellowship training in nuclear medicine and additional training to interpret the fluciclovine studies. A minority of studies were reviewed by a third fellowship-trained radiologist under the guidance of the two nuclear medicine-trained radiologists. In cases with abnormal radiopharmaceutical uptake in lymph nodes, the short-axis dimension of the lymph node or largest lymph node with abnormal uptake was noted. If CT or bone scan was performed within 4 months of the 18F-fluciclovine PET-CT, findings on the alternate imaging were compared with the results of the 18F-fluciclovine PET-CT. RESULTS: Our institutional positivity rate was 75.6%, with 64 (67.4%) patients with metastatic disease and 71 (52.6%) patients with local recurrence detected by fluciclovine. As expected, the rate of positive examinations increased with increasing PSA values measured at the time of imaging (P < 0.001). Of the 54 patients with nodal disease, 35 had nonpathologically enlarged lymph nodes measuring <1 cm in maximum short-axis dimension. In more than half of the patients in this study, with conventional imaging, fluciclovine either discovered otherwise undetectable metastatic disease or suggested the presence of local recurrence. CONCLUSIONS: Our single-institution experience with 18F-fluciclovine PET-CT has the largest number of patients to date in the literature and demonstrates the ability of fluciclovine to help guide clinical management in the detection of early recurrent disease.

Single Institution Experience of Stereotactic Body Radiation Therapy in Non-small Cell Lung Cancer: Comparison of Two Dose Regimes and a Perspective on Ideal Dose Regimens.

Introduction Stereotactic body radiation therapy (SBRT) is an effective treatment for early-stage non-small cell lung cancer (NSCLC) patients who are either medically inoperable or who decline surgery. SBRT improves tumor control and overall survival (OS) in medically inoperable, early-stage, NSCLC patients. In this study, we investigated the effectiveness of two different SBRT doses commonly used and present our institutional experience. Purpose To determine the clinical outcomes between two treatment regiments (50 Gray [Gy] vs. 55 Gy in five fractions) among Stage I NSCLC patients treated with SBRT at a state academic medical center. Methods We performed a retrospective analysis of 114 patients with Stage I (T1-2 N0 M0) NSCLC treated at a state academic medical center between October 2009 and April 2019. Survival analyses with treatment regimens of 50 Gy and 55 Gy in five fractions were conducted to detect any improvement in outcomes associated with the higher dose. The primary endpoints of this study included OS, local control (LC), and disease-free survival (DFS). Log-rank test and the Kaplan-Meier method were used to analyze the survival curves of the two treatment doses. The SPSS v.24.0 (IBM Corp., Armonk, NY, USA) was used for statistical analyses. Results The 114 early-stage NSCLC patients (median age, 68 years; range 12 to 87 years) had a median follow-up of 25 months (range two to 86 months). The number of males (n = 72; 63.2 %) exceeded the number of females (n = 42; 36.8 %). The majority of patients in this study were Caucasians (n = 68; 59.6 %) and 46 patients were African Americans (40.4 %). Two-thirds of the patients (n = 76; 66.7 %) were treated with 50 Gy in five fractions, and 38 patients (33.3 %) with 55 Gy in five fractions. The one-, two-, and three-year OS and DFS rates were improved in the patients treated with 55 Gy [OS, 81.7 % vs. 72.8 %; 81.7 % vs. 58.9 %; 81.7 % vs. 46.7 % (p = 0.049)], [DFS, 69.7 % vs. 69.7 %; 61.9 % vs. 55.7 %; 61.9 % vs. 52.0 % (p = 0.842)], compared to those treated with 50 Gy. Adenocarcinoma was the most common histology in both groups (51.3 % and 68.4 %). Failure rates were elevated for the 50 Gy regimen [39 (34.2 %) vs. 12 (8.5 %)]. Three year control rates were (66.3 % vs. 96.6 %; p = 0.002) local control; (63.3 % vs. 94.4 %; p = 0.000) regional control; and (65.7 % vs. 97.1 %; p = 0.000) distant control, compared to those treated with 55 Gy. Conclusion Early-stage NSCLC patients treated with SBRT 55 Gy in five fractions did better in terms of local control, overall survival, and disease-free survival rates compared to the 50 Gy in five fractions group.

The Will Rogers phenomenon, breast cancer and race.

BACKGROUND: The Will Rogers phenomenon [WRP] describes an apparent improvement in outcome for patients' group due to tumor grade reclassification. Staging of cancers is important to select appropriate treatment and to estimate prognosis. The WRP has been described as one of the most important biases limiting the use of historical cohorts when comparing survival or treatment. The main purpose of this study is to assess whether the WRP exists with the move from the AJCC 7th to AJCC 8th edition in breast cancer [BC] staging, and if racial differences are manifested in the expression of the WRP. METHODS: This is a retrospective analysis of 300 BC women (2007-2017) at an academic medical center. Overall survival [OS] and disease-free survival [DFS] was estimated by Kaplan-Meier analysis. Bi and multi-variate Cox regression analyses was used to identify racial factors associated with outcomes. RESULTS: Our patient cohort included 30.3% Caucasians [Whites] and 69.7% African-Americans [Blacks]. Stages I, II, III, and IV were 46.2, 26.3, 23.1, and 4.4% of Whites; 28.7, 43.1, 24.4, and 3.8% of Blacks respectively, in anatomic staging (p = 0.043). In prognostic staging, 52.8, 18.7, 23, and 5.5% were Whites while 35, 17.2, 43.5, and 4.3% were Blacks, respectively (p = 0.011). A total of Whites (45.05% vs. 47.85%) Blacks, upstaged. Whites (16.49% vs. 14.35%) Blacks, downstaged. The remaining, 38.46 and 37.79% patients had their stages unchanged. With a median follow-up of 54 months, the Black patients showed better stage-by-stage 5-year OS rates using 8th edition compared to the 7th edition (p = 0.000). Among the Whites, those who were stage IIIA in the 7th but became stage IB in the 8th had a better prognosis than stages IIA and IIB in the 8th (p = 0.000). The 8th showed complex results (p = 0.176) compared to DFS estimated using the 7th edition (p = 0.004). CONCLUSION: The WRP exists with significant variability in the move from the AJCC 7th to the 8th edition in BC staging (both White and Black patients). We suggest that caution needs to be exercised when results are compared across staging systems to account for the WRP in the interpretation of the data.

Factors Affecting Outcomes in Patients With Stage III & IV Squamous Cell Carcinoma of Oropharynx: The Importance of p16 Status, BMI, and Race.

Objective To identify racial disparities in survival outcomes among Stage III & IV patients with squamous cell carcinomas (SCCa) of the oropharynx treated with definitive radiation therapy (RT), with concurrent chemotherapy. Method This is a retrospective analysis of patients with stage III & IV SCCa of oropharynx treated with definitive RT at the State Academic Medical Center. All patients were treated to 70 Gy utilizing intensity-modulated radiation treatment (IMRT), and received concurrent chemotherapy with weekly cisplatin or cetuximab. Chi-square test was used to test the goodness of fit, overall survival (OS), and locoregional control (LRC) comparing races were generated by using Log-rank test & Kaplan-Meier method. The covariables associated with the OS and LRC were determined by the Cox regression model. A p-value of less than 0.05 was considered statistically significant. The SPSS 24.0 software (IBM Corp., Armonk, NY) was used. Results In the total 73 eligible patients, 54.8% were black, and 45.2% white patients. Stage distribution (per American Joint Committee on Cancer-AJCC 8th Ed) between black patients vs. white patients, Stage III (45.5% vs. 54.5%) and for Stage IV (56.5% vs. 43.5%); p=0.499. Median follow-up for the entire group was 41 months (range: 4-144 months). In the univariate analysis, variables p16 status, body mass index (BMI), alcohol history and tumor subsite were found to be significant. In the multivariate analysis, only BMI has shown to be significant. Three-year LRC for black patients was 37.8% vs.66.8% in white patients (p=0.354) and three-year OS for black patients was 51.8% vs. 80.9% for white patients (p=0.063), respectively. Five-year OS for p16 positive patients was 69.7% vs. 43% for p16 negative patients (p=0.034). Five-year OS for Stage IV black patients was 34% vs. 69.5% for Stage IV white patients (p=0.014). Conclusion Among all the co-variables examined, only BMI has shown affecting the OS outcomes; gender and BMI shown to be affecting the LRC. Racial factor appears to be significant in Stage IV patients.

Quality-Adjusted Life Years and Disability-Adjusted Life Years Are Better With Concurrent Chemoradiation Therapy Than Induction Chemotherapy Followed by Chemoradiation Therapy in Nasopharyngeal Carcinoma.

Introduction As traditional measures such as overall survival (OS) or disease-free survival (DFS) alone do not give a holistic view of the outcomes of a treatment paradigm, we determine to add the evidence of quality-adjusted life year (QALY) and disability-adjusted life year (DALY) to the outcomes of the nasopharyngeal carcinoma patients (NCP) treated with definitive chemoradiation therapy (chemoRT) with or without induction chemotherapy (induction chemo). Methods This is a retrospective analysis of 85 NCPs treated at an academic state institution. The OS estimated by the Kaplan-Meier method and the multivariate Cox regression model determined the co-variables associated with the OS. The relationship between QALYs gained and DALYs saved were calculated from age of the disease onset, duration of the disease, quality of life (QoL) and disability weights. Results Of the 85 eligible NCPs of this cohort, the disease frequency distribution per the World Health Organization (WHO) classification was 41.2% for Type-I, 42.4% for Type-II, and 16.5% for Type-III. The median follow-up (24 months). The five-year OS of patients treated with concurrent chemoRT vs. induction chemo followed by concurrent chemoRT was 54.7 vs. 14.8% for WHO Type I, 60.1 vs. 58.3% for WHO Type II, and 83.3 vs. 50.0% for WHO Type III (p=0.029). The average DALYs saved with concurrent chemoRT were 12.2 years vs. 5 years for induction chemo followed by concurrent chemoRT. The average QALYs gained with concurrent chemoRT were 6.9 years vs. 3.1 years for induction chemo followed by concurrent chemoRT. Conclusion Patients treated with concurrent chemoRT had an increased QoL when compared to induction chemo followed by concurrent chemoRT. The average DALYs saved were higher in the patients treated with concurrent chemoRT than treated with induction chemo followed by concurrent chemoRT.

Do We Need a New Approach to Cancer Biology Education for Radiation Oncology Residents?

Traditional radiation oncology biology courses largely focus on radiation biology and oncology as needed for passing the boards. Changes in the landscape of oncology necessitate a broader scope. Radiotherapy is an important component of cancer care. Approximately 70% of all cancer patients receive radiotherapy during the course of their disease. With the revolution in precision medicine that is unfolding, genomics, proteomics, metabolomics, and microbiomics are being ever more integrated into the treatment of cancer. Comprehensive knowledge of cancer biology beyond traditional radiation biology is essential for future advances in radiotherapy and unavoidable for radiation oncology trainees. The importance of a newly designed curriculum to impart broader knowledge to future radiation oncologists is emphasized in this report. A paradigm shift in the approach to the traditional radiation biology course is required to train residents for the future of oncology.

A 25-year Experience at an Academic Medical Center in the United States: Are There Racial Disparities in the Prognosis of Patients Diagnosed With Hypopharyngeal Carcinoma?

Introduction This study attempted to identify disparities in outcomes between African American (AA) and Caucasian American (CA) patients treated for hypopharyngeal carcinoma at a tertiary care institution over the past 25 years. Methods An institutional review board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPPA)-compliant retrospective analysis was performed on patients with squamous cell carcinoma of the hypopharynx treated at our institution between January 1994 and December 2018. Data regarding demographics, stage, treatment, and follow-up were collected. Outcomes, including median survival and overall survival, were calculated using the Kaplan-Meier method. All analyses were performed using the Social Packages for the Social Sciences (SPSS) v. 24 (IBM Corp., Armonk, NY). Results We identified 144 hypopharyngeal carcinoma patients who were treated during this period. Our patient cohort consisted of 61.8% AA and 35.4% CA (P=0.538). Overall, 96% of them presented at an advanced stage (Stages III & IV) of the disease, and only 4% presented in the early stages (Stages I & II). There was no significant difference between AA and CA patients who presented with advanced disease (96.6% vs. 94.1%). In our patient cohort, 15.3% of patients did not receive any therapy; however, 51.4%, 22.9%, and 10.4% of them underwent definitive chemoradiotherapy, definitive surgery, or palliative chemotherapy, respectively. There were no significant differences in patient racial proportions within each treatment group. The median follow-up of the entire cohort was 13 months. There was no significant difference between the median survival of AA and that of CA patients (16 months vs. 15 months; p=0.917). Moreover, there was no significant difference in the overall survival between AA and CA patients at three years (27.2% vs. 36.3%; p=0.917) and five years (20.4 % vs. 16.7 %; p=0.917). Conclusions A retrospective review of patients with hypopharyngeal cancer treated at our institution over the previous 25 years did not identify significant racial disparities regarding the stage at presentation or prognosis. This study suggests that when patients have equal access to care, they appear to have a similar prognosis despite racial differences. Further studies are needed to validate this hypothesis.

Management of Advanced-stage Hypopharyngeal Carcinoma: 25-Year Experience from a Tertiary Care Medical Center.

Introduction Due to conflicting data in the literature, there is a continuing debate on whether advanced hypopharyngeal carcinoma patients should be treated with definitive surgery or chemoradiotherapy. The purpose of this study is to evaluate the management and outcomes of advanced hypopharyngeal carcinoma in a tertiary care institution over the last 25 years. Methods An Institutional Review Board (IRB)-approved and HIPPA-compliant retrospective analysis was performed of patients with advanced-stage squamous cell carcinoma of the hypopharynx treated at our institution between January 1994 and December 2018. Data regarding demographics, stage, treatment, and follow-up were collected. Outcomes including median survival and overall survival were calculated using the Kaplan Meier method. All analyses were performed using SPSS v. 24.  Results This study included a total of 103 advanced stage hypopharyngeal cancer patients. The median age for this cohort is 61 years (range: 41-88, SD 9.3). Of the total 103 eligible patients treated, 92 (89.3%) were male and 11 (10.7%) female; 61 (59.2%) were African Americans, 39 (37.9%) were Caucasians and three (2.9%) were other races. Seventeen patients (16.5%) had stage III disease, whereas 86 (83.5%) patients were diagnosed with Stage IV A or B disease. Seventy-two patients (69.9%) were treated with definitive chemoradiotherapy (ChemoRT group), and 31 patients (30.1%) underwent primary surgery with or without adjuvant treatments (Surgery group). The two treatment groups were similar in terms of age, gender, ethnicity, alcohol status, N staging, and subsites but were significantly different for smoking status (p = 0.035) and T staging (p = 0.024). The median follow-up was 17 months. The median survival of the overall cohort was 26 months, and five-year overall survival was 25.5%. The median survival was found to be significantly better for the surgery group as compared to the definitive chemoradiotherapy group (43 months vs 16 months, p = 0.049). The five-year overall survival (OS; 41.5% vs 18.5%, p = 0.049) and disease-free survival (DFS; 75.3% vs 56%; p = 0.029) were significantly better for patients in the surgery group compared to the chemoradiotherapy group. On multivariate Cox-regression analysis, lymph nodal status (HR = 1.27, CI: 1.00-1.62, p = 0.047) and chemoradiation treatment (HR = 1.82, CI: 1.00-3.29, p = 0.048) were associated with higher risk of mortality.  Conclusion In our single institutional experience of advanced hypopharyngeal carcinoma management, the five-year overall survival rate was found to be 25.5 % and was the poorest among head and neck cancers. The patients with advanced hypopharyngeal cancer treated with surgery followed by adjuvant radiation or chemoradiation have significantly improved overall survival compared to those treated with definitive chemoradiotherapy. Further research warranted for early detection and better treatment to improve the cure rate in hypopharyngeal carcinoma patients.

Use of Amifostine for Cytoprotection during Radiation Therapy: A Review.

BACKGROUND: Radiation therapy is a cornerstone of the therapeutic modalities used in modern oncology. However, it is sometimes limited in its ability to achieve optimal tumor control by radiation-induced normal tissue toxicity. In delivering radiation therapy, a balance must be achieved between maximizing the dose to the tumor and minimizing any injury to the normal tissues. Amifostine was the first Food and Drug Administration (FDA)-approved clinical radiation protector intended to reduce the impact of radiation on normal tissue, lessening its toxicity and potentially allowing for increased tumor dose/control. Despite being FDA-approved almost 20 years ago, Amifostine has yet to achieve widespread clinical use. SUMMARY: A thorough review of Amifostine's development, mechanism of action, and current clinical status were conducted. A brief history of Amifostine is given, from its development at Walter Reid Institute of Research to its approval for clinical use. The mechanism of action of Amifostine is explored. The results of a complete literature review of all prospective randomized trials to date involving the use of Amifostine in radiation therapy are presented. The results are arranged by treatment site and salient findings discussed. Side effects and complications to consider in using Amifostine are reviewed. Key Messages: Amifostine has been explored as a radiation protectant in most radiation treatment sites. Studies have demonstrated efficacy of Amifostine in all treatment sites reviewed, but results are heterogeneous. The heterogeneity of studies looking at Amifostine as a clinical radiation protectant has precluded a definitive answer on its efficacy. Complicating its clinical use is its toxicity and delivery requirements. Amifostine has largely fallen out of use with the advent of intensity modulated radiation therapy (IMRT). However, side effects with IMRT remain a challenge and concern. The use of Amifostine in the IMRT era has been poorly explored and is worthy of future study.

The Impact of a Postmastectomy Chest Wall Scar Boost on Local Recurrence-free Survival in High-risk Patients.

INTRODUCTION: A scar boost following postmastectomy radiation to a total dose of > 50 Gy can be considered in cases of invasive breast cancer with high-risk features including advanced tumor stage, lymphovascular space invasion (LVSI), and positive margins. The purpose of this study was to determine the impact of a scar boost on 5-year local recurrence-free survival (LRFS). MATERIALS AND METHODS: We retrospectively analyzed 140 patients with invasive breast cancer treated with mastectomy and postmastectomy radiation at a single institution between 2007 and 2016. Patients received 50 to 50.4 Gy to the chest wall and the majority of scar boosts were 9 to 10 Gy. LRFS was examined using the Kaplan-Meier method and univariable Cox regression. RESULTS: A total of 140 patients met inclusion criteria with a median follow-up time of 48 months. Ninety-four (67.1%) patients did receive a scar boost and 46 (32.9%) patients did not. On subset analysis of patients with LVSI or positive margins, 5-year LRFS was 79.3% in patients treated with scar boost compared with 71.1% in patients without a scar boost (P = .537). In patients with T3 or T4 disease, 5-year LRFS was 80.9% in those who received scar boost and 71.6% in patients who did not (P = .967). The use of a scar boost was not associated with a significant improvement in LRFS on Cox regression (hazard ratio, 0.83; 95% confidence interval, 0.37-1.84; P = .654). CONCLUSION: Use of a scar boost following postmastectomy radiation decreased the absolute percentages of local recurrences in patients with high-risk features; however, this did not translate into a statistically significant benefit.