Salvage Abdominoperineal Resection for Anal Squamous Cell Carcinoma: Use, Risk Factors, and Outcomes in a Canadian Population.

BACKGROUND: Previous studies have reported that 30% to 40% of patients with squamous cell carcinoma of the anus will require salvage abdominoperineal resection after chemoradiotherapy. OBJECTIVE: The purpose of this study was to identify the use, risk factors, and impact on survival of salvage abdominal perineal resection for squamous cell carcinoma of the anus. DESIGN: This was a retrospective, population-based cohort study. SETTINGS: Patients treated in Ontario, Canada through a single-payer universal healthcare system, were included. PATIENTS: Patients included all incident cases of squamous cell anal cancer who underwent curative intent radiotherapy from 2007 to 2015. MAIN OUTCOME MEASURES: Risk of salvage abdominoperineal resection, factors associated with salvage abdominoperineal resection, and survival were measured. RESULTS: A total of 1125 patients were treated with curative intent radiotherapy for squamous cell cancer of the anus. Within this cohort, salvage surgery was performed in 8% (93/1125), whereas 14% (156/1125) required a permanent colostomy. In log-binomial regression, younger age was associated with salvage surgery, whereas sex, cancer stage, socioeconomic status, and HIV were not. There was a suggested lower risk of salvage surgery in those who completed chemoradiation (relative risk = 0.67 (95% CI, 0.43-1.03)). Crude 5-year overall survival rate was 73% (95% CI, 70%-76%) in those not requiring salvage surgery and 48% (95% CI, 37%-58%) in those who did. In Cox models, mortality was higher in patients requiring salvage surgery compared with those who did not (adjusted HR = 2.20 (95% CI, 1.65-2.94), whereas improved survival was seen in those who completed chemoradiation (HR = 0.65 (95% CI, 0.42-0.82)) LIMITATIONS:: The study was limited by its potential residual confounding by indication for salvage surgery. CONCLUSIONS: In this large, contemporary cohort of patients with squamous cell carcinoma of the anus, the proportion of patients undergoing salvage surgery was considerably lower than previous reports. Younger age was associated with salvage surgery, and there was a suggestion of lower risk of salvage surgery with completion of chemoradiation. Patients requiring salvage surgery had poor 5-year overall survival. See Video Abstract at http://links.lww.com/DCR/B205. RAP DE RESCATE PARA EL CARCINOMA ANAL DE CéLULAS ESCAMOSAS: USO, FACTORES DE RIESGO Y RESULTADOS EN UNA POBLACIóN CANADIENSE: Estudios anteriores han reportado que 30-40% de los pacientes con carcinoma de células escamosas del ano requerirán una resección abdominoperineal de rescate después de la quimiorradioterapia.Identificar la utilización, los factores de riesgo y el impacto en la supervivencia de la resección abdominoperineal de rescate para el carcinoma de células escamosas del ano.Estudio de cohorte retrospectivo, basado en la población.Todos los casos incidentes de cáncer anal de células escamosas que se sometieron a radioterapia con fines curativos de 2007 a 2015.Pacientes tratados en Ontario, Canadá, un sistema de salud universal de un solo pagador.Riesgo de resección abdominoperineal de rescate, factores asociados con la resección abdominoperineal de rescate y la supervivencia.1125 pacientes fueron tratados con radioterapia de intención curativa para el cáncer de células escamosas del ano. Dentro de esta cohorte, la cirugía de rescate se realizó en el 8% (93/1125), mientras que el 14% (156/1125) requirió una colostomía permanente. En la regresión log-binomial, la edad más joven se asoció con la cirugía de rescate, mientras que el sexo, la etapa del cáncer, el estado socioeconómico y el VIH no. Se sugirió un menor riesgo de cirugía de rescate en aquellos que completaron la quimiorradiación (RR 0,67; IC del 95%: 0,43 a 1,03). La tasa de supervivencia global bruta a 5 años fue del 73% (IC del 95%: 70-76%) en aquellos que no requirieron cirugía de rescate y del 48% (IC del 95%: 37-58%) en los que sí lo requirieron. En los modelos de Cox, la mortalidad fue mayor en los pacientes que requirieron cirugía de rescate en comparación con aquellos que no lo requirieron (HR ajustado 2.20, IC 95%: 1.65 - 2.94), mientras que se observó una mejor supervivencia en aquellos que completaron la quimiorradiación (HR 0.65, IC 95% 0.42 - 0,82).Posible confusión residual por indicación de cirugía de rescate.En esta gran cohorte contemporánea de pacientes con carcinoma de células escamosas del ano, la proporción de pacientes sometidos a cirugía de rescate fue considerablemente menor que los informes anteriores. La edad más temprana se asoció con la cirugía de rescate, y se sugirió un menor riesgo de cirugía de rescate con la finalización de la quimiorradiación. Los pacientes que requirieron cirugía de rescate tuvieron una deficiente supervivencia general de 5 años. Consulte Video Resumen en http://links.lww.com/DCR/B205. (Traducción-Dr Gonzalo Hagerman).

Piloting prostate cancer patient-reported outcomesin clinical practice.

PURPOSE: The expanded prostate cancer index composite-26 (EPIC-26) instrument is a validated research tool used for capturing patient-reported quality-of-life outcomes related to the domains of bowel, bladder, and sexual functioning for men undergoing curative treatment for prostate cancer. The purpose of this pilot study was to explore the perceptions and experiences of clinicians with using EPIC-26 in a clinical setting for patients receiving curative radiotherapy. METHODS: Ten clinicians reviewed EPIC-26 scores either before or during weekly clinical encounters with patients receiving curative radiation treatment for prostate cancer. After a period of 2 months, clinicians underwent individual semi-structured interviews where they were asked about their views on measuring patient-reported outcomes in practice, the value of EPIC-26, impressions on patient acceptability, and operational issues. RESULTS: There was a general willingness and acceptance by clinicians to use EPIC-26 for routine clinical practice. Clinician participants found EPIC-26 to be generally informative, and added value to the clinical encounter by providing additional information that was specific to prostate cancer patients. EPIC-26 was also felt to improve overall communication and provide additional insight into the patient experience. CONCLUSIONS: Our qualitative findings suggest that there may be a role for incorporating patient-reported outcome measure assessment tools like EPIC-26 routinely into clinical practice. However, further qualitative and quantitative research is required in order to assess the impact of patient-reported outcome information on communication, patient and clinician satisfaction, and how these and other related outcomes can be used for guiding treatment decision-making.

Aligning Requirements of Training and Assessment in Radiation Treatment Planning in the Era of Competency-Based Medical Education.

PURPOSE: Radiation treatment planning (RTP) is a unique skill that requires interdisciplinary collaboration among radiation oncologists (ROs), dosimetrists, and medical physicists (MP) to train and assess residents. With the adoption of competency-based medical education (CBME) in Canada, it is essential residency program curricula focuses on developing competencies in RTP to facilitate entrustment. Our study investigates how radiation oncology team members' perspectives on RTP education align with requirements of the CBME approach, and its implications for improving residency training. METHODS AND MATERIALS: This qualitative research study took place in the Department of Oncology at a midsize academic institution. Through convenience sampling, focus groups were conducted with radiation oncologists (n = 11), dosimetrists (n = 7), medical physicists (n = 7), and residents (n = 7). Thematic design was adopted to analyze the transcripts through open coding resulting in 3 overarching themes. RESULTS: The results identified existing strengths and weaknesses of the residency program and future opportunities to redesign the curriculum and assessment process within a CBME model. Three overarching themes emerged from the analysis: (1) the strengths of RTP in the CBME environment; (2) challenges of RTP in CBME; and (3) opportunities for change. Stakeholders were optimistic CBME will help enrich resident learning with the increased frequency and quality of competency-based assessments. Participants suggested building a library of cases and developing computer-based learning resources to provide a safe environment to develop skills in contouring, dosimetry, and plan evaluation, in accordance with CBME training. CONCLUSIONS: This study identified future opportunities to redesign the RTP curriculum and assessment process within a CBME model. The need for innovative teaching and learning strategies, including case libraries, computer-based learning, and quality assessments, were highlighted in designing an innovative RTP planning curriculum.

Factors Associated With Chemoradiation Therapy Interruption and Noncompletion Among Patients With Squamous Cell Anal Carcinoma.

Importance: Definitive chemoradiation for anal cancer is effective but may be associated with toxic effects, and some patients may not be able to complete the planned treatment. Identifying factors associated with treatment interruption and noncompletion is important to target quality improvement efforts. Objective: To identify rates of chemoradiation treatment interruption or noncompletion and factors associated with this among patients with anal cancer treated in routine clinical practice. Design, Setting, and Participants: In this population-based, retrospective cohort study, the Ontario Cancer Registry was used to identify all incident cases of squamous cell anal cancer treated with curative-intent radiation from 2007 to 2015 in Ontario, Canada. Final analysis of data was performed on August 9, 2019. Exposures: Curative-intent radiation therapy. Main Outcomes and Measures: Treatment interruption was defined as more than 7 days between fractions of radiation. Radiation completion was defined as receipt of 45 Gy or more and 25 fractions of radiation. Chemoradiation completion was defined as radiation completion and 2 doses of combination chemotherapy. Associations between patient factors and treatment interruption and noncompletion were estimated with log-binomial models. Cox proportional hazard models were used to estimate the association of treatment interruption or noncompletion with all-cause death, cancer-specific death, and the combined outcome of colostomy or death. Results: Overall, 1125 patients with stage I-III anal cancer were treated with curative-intent radiation. Treatment interruptions occurred in 262 (23%). Radiation and chemoradiation noncompletion occurred in 199 (18%) and 280 (25%), respectively. No associations were found to correlate with an increased risk of treatment interruption. Patients older than 70 years were less likely to complete chemoradiation (risk ratio [RR], 0.60; 95% CI, 0.52-0.70), compared with those younger than 50 years. Patients with a higher number of comorbidities were also less likely to complete chemoradiation (RR, 0.70; 95% CI, 0.51-0.95). Patients who did not complete chemoradiation had a higher risk of requiring salvage abdominoperineal resection (RR, 1.54; 95% CI, 1.03, 2.31), overall death (hazard ratio [HR], 1.54; 95% CI, 1.23-1.92), cancer-specific death (HR, 1.59; 95% CI, 1.14-2.22), and colostomy or death (HR, 1.80; 95% CI: 1.10-2.93). Treatment interruptions longer than 7 days were not associated with death. Conclusions and Relevance: Many patients undergoing curative-intent chemoradiation for anal cancer experienced treatment interruption or noncompletion. Quality improvement initiatives to optimize treatment continuity and completion are needed.