Patient-reported outcomes of the relative severity of side effects from cancer radiotherapy.

PURPOSE: It is not known which side effects (SEs) cancer patients undergoing definitive radiotherapy (RT) perceive as worse than others. Our objectives were to (1) identify the worst SEs in patients receiving definitive RT-predominant treatment using patient-reported outcomes and (2) investigate the prominence of physical SEs relative to psychosocial SEs. METHODS: In a single-center outpatient radiation oncology clinic, patients were surveyed on the final day of definitive RT. Sixty-seven cards listed SEs (40 physical and 27 psychosocial), and patients ranked the five most severe. Fifteen points were assigned to the top five selected SEs with descending scores of 5, 4, 3, 2, and 1. RESULTS: Fifty-five patients completed ≥ 4 weeks of RT with or without concurrent chemotherapy and had not received ≥ 4 weeks of neoadjuvant chemotherapy. Patients with head and neck and pelvis cancers perceived physical SEs as worse relative to psychosocial SEs; physical SEs filled 78% and 69% of the 15 points, respectively. In breast cancer patients, however, psychosocial SEs filled 45% of the 15 points in breast cancer patients (anxiety, depression, and sequelae), compared to 25% in others (P = 0.007). Affects my work, home duties, a SE not associated with the treatment itself, was the most frequently cited psychosocial SE (20% of cohort) and was ranked ninth overall. CONCLUSION: Perceptions of SEs of cancer RT are dominated by physical quality of life (QoL) concerns and are influenced by the anatomic area receiving RT. Psychosocial QoL concerns are significantly more frequent in breast cancer patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02978846.

Safety-net versus private hospital setting for brain metastasis patients treated with radiosurgery alone: Disparities in follow-up care and outcomes.

BACKGROUND: Stereotactic radiosurgery (SRS) alone is an increasingly accepted treatment for brain metastases, but it requires adherence to frequently scheduled follow-up neuroimaging because of the risk of distant brain metastasis. The effect of disparities in access to follow-up care on outcomes after SRS alone is unknown. METHODS: This retrospective study included 153 brain metastasis patients treated consecutively with SRS alone from 2010 through 2016 at an academic medical center and a safety-net hospital (SNH) located in Los Angeles, California. Outcomes included neurologic symptoms, hospitalization, steroid use and dependency, salvage SRS, salvage whole-brain radiotherapy, salvage neurosurgery, and overall survival. RESULTS: Ninety-three of the 153 patients were private hospital (PH) patients, and 60 were SNH patients. The median follow-up time was 7.7 months. SNH patients received fewer follow-up neuroimaging studies (1.5 vs 3; P = .008). In a multivariate analysis, the SNH setting was a significant risk factor for salvage neurosurgery (hazard ratio [HR], 13.65; P < .001), neurologic symptoms (HR, 3.74; P = .002), and hospitalization due to brain metastases (HR, 6.25; P < .001). More clinical visits were protective against hospitalizations due to brain metastases (HR, 0.75; P = .002), whereas more neuroimaging studies were protective against death (HR, 0.65; P < .001). CONCLUSIONS: SNH patients with brain metastases treated with SRS alone had fewer follow-up neuroimaging studies and were at higher risk for neurologic symptoms, hospitalization for brain metastases, and salvage neurosurgery in comparison with PH patients. Clinicians should consider the practice setting and patient access to follow-up care when they are deciding on the optimal strategy for the treatment of brain metastases. Cancer 2018;124:167-75. © 2017 American Cancer Society.

Anterior plaque brachytherapy placement for treatment of iris and iridociliary melanomas - Surgical procedure and institutional experience.

Surgical placement of eye plaque brachytherapy (EPB) is the standard of care for the treatment of uveal melanomas, including iris/iridociliary melanomas. However, unique challenges exist in anterior EPB placement. Here, we describe a surgical technique for anterior EPB placement when placement requires plaque positioning onto the cornea. Blunt conjunctival peritomy exposes the sclera overlying the tumor. A "dummy" plaque is placed, with positioning confirmed by direct visualization. The amniotic membrane is draped across the cornea and anchored with the eyelet sutures, the plaque is placed overlying the membrane, the conjunctiva is closed over the plaque, and a temporary tarsorrhaphy is performed. One week later, the conjunctival incision is reopened for plaque/amniotic membrane removal. This technique was employed in the treatment of 12 iris/iridociliary melanomas at our institution, with no instances of corneal damage. In placing an anterior plaque, employing this technique allows appropriate cancer treatment while optimizing patient comfort and corneal integrity.

Outpatient ocular brachytherapy: The USC Experience.

PURPOSE: Ocular brachytherapy is a standard-of-care surgical procedure for globe salvage in the treatment of uveal melanoma. The procedure involves the placement and subsequent removal of a radioactive plaque several days later. At many locations, patients are admitted on an inpatient basis until plaque removal due to radiation safety concerns. However, patients may be discharged to home after plaque insertion, and subsequently return to the medical facility for plaque removal. This study aimed to evaluate the safety and systematic financial benefit of the outpatient ocular brachytherapy program at "?>the University of Southern California (USC) Roski Eye Institute for 30 years. METHODS AND MATERIALS: A single-institution retrospective record review was performed on all 275 patients who underwent brachytherapy for ocular tumors between January 1, 1989 and December 31, 2019 to assess for occurrences of reportable radiation and/or patients safety events. The treatment protocols at our institution are described. Data on hospital-adjusted expenses per inpatient day from the American Hospital Association's 2018 Annual Survey were used as a proxy for costs to patients and the health care system to perform a cost-benefit analysis comparing outpatient versus inpatient brachytherapy. RESULTS: Of the 275 plaque procedures over a 30-year period that were reviewed, there were no internally or externally reportable patient or radiation safety events. There were no adverse events related to patient transportation to the hospital, the patient not returning for plaque removal, operative issues in removing the plaque on time due to cancelled or delayed cases, or loss of radioactive material. Additionally, our cost-benefit analysis estimates that outpatient brachytherapy reduced costs for USC's patients in 2018 by an average of $24,722 per patient treated with ocular brachytherapy. CONCLUSIONS: With appropriate measures, outpatient ocular brachytherapy allows patients to safely return home with the added benefit of decreased financial burden for both patients and the broader health care system.

Accreditation Program for Excellence (APEx): A Catalyst for Quality Improvement.

PURPOSE: In 2014 the American Society for Radiation Oncology's Accreditation Program for Excellence (APEx) was created in response to the Target Safely campaign. APEx is a powerful tool to measure and drive quality improvement in radiation oncology practices. METHODS AND MATERIALS: A task group from the American Society for Radiation Oncology's Practice Accreditation Committee was formed to provide an overview of the APEx accreditation program including analysis from specific program data. RESULTS: Through initiatives encouraged by the APEx program, participants are able to evaluate teamwork and effectiveness, implement documented procedures aimed at improving quality and safety, and establish quality management at the practice. The program's Self-Assessment measures performance with program requirements and indicates where compliance lacks standardization. Methods to address these deficiencies form part of on-going quality improvement. These quality outcomes promote the delivery of safe, high-quality care. CONCLUSION: The accreditation process through APEx is a commitment to an ongoing safety culture. Any worthwhile accreditation program should provide a meaningful assessment of practice operations, supply the tools to identify deficiencies and provide the opportunity to showcase growth and development. A commitment to completing APEx is a commitment to excellence for patients and all those who care for them.

Quantifying Subclinical and Longitudinal Microvascular Changes Following Episcleral Plaque Brachytherapy Using Spectral Domain-Optical Coherence Tomography Angiography.

PURPOSE: To assess longitudinal microvascular changes in eyes treated with I-125 episcleral plaque brachytherapy (EPB). METHODS: High resolution OCT angiograms of the central 3×3mm macula were obtained from I-125 episcleral plaque brachytherapy treated and untreated fellow eyes of 61 patients. Capillary density (vessel skeleton density, VSD) and caliber (vessel diameter index, VDI) were quantified using previously validated semi-automated algorithms. Nonperfusion was also quantified as flow impairment regions (FIR). Exams from treated and fellow eyes obtained pre-treatment and at 6-month, 1-year, and 2-year intervals were compared using generalized estimating equation linear models. Dosimetry maps were used to evaluate spatial correlation between radiation dose and microvascular metrics. RESULTS: At 6 months, treated eyes had significantly lower VSD (0.145 ± 0.003 vs 0.155 ± 0.002; p = 0.009) and higher FIR (2.01 ± 0.199 vs 1.46 ± 0.104; p = 0.010) compared to fellow eyes. There was a significant decrease in VSD and a corresponding increase in FIR even for treated eyes without clinically identifiable retinopathy at 6 months. VDI was significantly higher in treated eyes than in fellow eyes at 2 years (2.92 ± 0.025 vs 2.84 ± 0.018; p < 0.001). When our cohort was categorized into low dose radiation (<15Gy) and high dose radiation (>45Gy) to the fovea, there were significant differences in VSD and FIR between groups. CONCLUSIONS: OCTA can be used to quantify and monitor EPB induced retinopathy, and can detect vascular abnormalities even in the absence of clinically observable retinopathy. OCTA may therefore be useful in investigating treatment interventions that aim to delay EPB-induced radiation retinopathy.

Practice Patterns for the Treatment of Uveal Melanoma with Iodine-125 Plaque Brachytherapy: Ocular Oncology Study Consortium Report 5.

BACKGROUND: Treatment planning for I-125 plaque therapy for uveal melanoma has advanced significantly since the Collaborative Ocular Melanoma Study trial, with more widely available image-guided planning and improved dosimetry. OBJECTIVE: We evaluated real-world practice patterns for I-125 plaque brachytherapy in the United States by studying practice patterns at centers that comprise the Ocular Oncology Study Consortium (OOSC). METHODS: The OOSC database and responses to a treatment practice survey were evaluated. The database contains treatment information from 9 institutions. Patients included in the database were treated between 2010 and 2014. The survey was conducted in 2018 and current treatment planning methods and prescriptions were queried. RESULTS: Examination of the OOSC database revealed that average doses to critical structures were highly consistent, with the exception of one institution. Survey responses indicated that most centers followed published guidelines regarding dose and prescription point. Dose rate ranged from 51 to 118 cGy/h. As of 2018, most institutions use pre-loaded plaques and fundus photographs and/or computed tomography or magnetic resonance imaging in planning. CONCLUSIONS: While there were differences in dosimetric practices, overall agreement in plaque brachytherapy practices was high among OOSC institutions. Clinical margins and planning systems were similar among institutions, while prescription dose, dose rates, and dosimetry varied.

The Cancer Bell: Too Much of a Good Thing?

PURPOSE: Patients around the world often ring a bell on the final day of radiation therapy (RT) to celebrate treatment completion. Patients appear to enjoy ringing the bell, but its psychological impact is unexamined. Applying a psychological principle named the "peak-end rule," we hypothesized that ringing the bell would improve patients' perceptions of the overall distress from cancer treatment. METHODS AND MATERIALS: We enrolled 2 cohorts of patients completing definitive RT in a single-center outpatient radiation oncology clinic. Patients in the control arm completed treatment and filled out the survey mentioned below. A bell was then installed in the clinic, and patients in the intervention arm rang the bell on the final day of RT and filled out the same survey. Patients evaluated their overall distress from cancer treatment using a survey composed of an 11-point numerical rating scale in combination with the Verbal Rating Scale. At follow-up, a shorter survey was completed that asked the same questions about distress from cancer treatment. RESULTS: Two hundred ten patients were enrolled, 107 in the bell group and 103 in the control group. One hundred sixty-three patients completed follow-up surveys, n = 86 (80%) and n = 77 (75%) in the bell and control groups, respectively. Demographics and treatment characteristics were well balanced. The bell group reported worse overall distress scores than those not ringing the bell (mean [standard deviation] 5.6 [2.8] vs 4.7 [2.7], P = .045). This difference worsened further at follow-up (6.4 [2.9] vs 5.1 [3.0], P = .009; mean 103 vs 130 days, P = .056). CONCLUSIONS: Counter to our hypothesis, ringing the bell on the final day of RT worsens patients' evaluation of overall distress from cancer treatment, and this distress persists and even worsens in the months after treatment. Emotional arousal created by ringing the bell may magnify the distress from cancer treatment and subsequently worsen the perception of distress from treatment.

Trends in Radiation Practices for Female Ocular Oncologists in North America: A Collaborative Study of the International Society of Ocular Oncology.

BACKGROUND: The aim of this study was to determine the known radiation exposure, attitudes, and consequent risk modifications among female ocular oncologists in North America who routinely administer radioactive plaque brachytherapy treatment and are members of the International Society of Ocular Oncology. METHODS: Nineteen female ocular oncologists completed an anonymous 17-question radiation exposure survey. RESULTS: Eleven of the participants chose to routinely wear lead protection during surgery; 8 did not. Fifteen of 19 participants reported using an unloaded "nonactive" template to prepare for plaque implantation. During pregnancy, 11 of 13 participants continued to perform plaque brachytherapy. Eight of these 11 undertook measures to decrease radiation exposure self-reported as lead wear and other. The average reported anxiety regarding fertility was 2.1 (SD, 2.2) on a scale from 1 to 10. CONCLUSION: This study corroborates prior literature that surgeons' exposure to radiation during plaque brachytherapy is minimal. Nonetheless, there remains some anxiety regarding exposure risk to women, due to potential effects on fertility and fetal health. We found variability in exposure monitoring, required training, and precautions during pregnancy amongst this group of surgeons. Improved education and clearer pregnancy guidelines may equip female ocular oncologists with optimal knowledge regarding risk of radiation exposure.

Outcomes of choroidal melanomas treated with eye physics plaques: A 25-year review.

PURPOSE: To review long-term outcomes of the University of Southern California Plaque Simulator (PS) software and Eye Physics (EP) plaques. We hypothesize that the PS/EP system delivers lower doses to critical ocular structures, resulting in lower rates of radiation toxicity and favorable visual outcomes compared to Collaborative Ocular Melanoma Study plaques, while maintaining adequate local tumor control. METHODS AND MATERIALS: Retrospective review of 133 patients treated for choroidal melanoma with 125I brachytherapy, using PS software and EP plaques, from 1990 through 2015. A dose of 85 Gy at a rate of 0.6 Gy/h was prescribed to the tumor apex (with a typical margin of 2 mm) over 7 days. Primary outcomes were local tumor recurrence, globe salvage, and metastasis. Secondary outcomes were changes in visual acuity and radiation complications. RESULTS: With median followup of 42 months, 5-year Kaplan-Meier estimated rates for tumor control, globe salvage, and metastatic-free survival were 98.3%, 96.4%, and 88.2%, respectively. Median doses to the macula and optic nerve were 39.9 Gy and 30.0 Gy, respectively. Forty-three percent of patients developed radiation retinopathy, and 20% developed optic neuropathy; 39% lost ≥6 Snellen lines of vision. CONCLUSIONS: The PS/EP system is designed to improve the accuracy and conformality of the radiation dose, creating a steep dose gradient outside the melanoma to decrease radiation to surrounding ocular structures. We report favorable rates of local tumor control, globe salvage, metastases, and radiation complications when compared to the Collaborative Ocular Melanoma Study and other studies. Overall, the PS/EP system results in excellent tumor control and appears to optimize long-term visual and radiation-related outcomes after brachytherapy.

Induction docetaxel, Cisplatin, and 5-Fluorouracil precludes definitive chemoradiotherapy in a substantial proportion of patients with head and neck cancer in a low socioeconomic status population.

OBJECTIVES: In this retrospective study we evaluate the tolerability and outcomes after induction chemotherapy for patients with predominately low socioeconomic status (SES) with locally advanced head and neck cancer (LAHNC). METHODS: One hundred eighteen patients with LAHNC of the hypopharynx, larynx, oral cavity, or oropharynx began curative intent therapy with induction cisplatin (75 or 100 mg/m), docetaxel (75 mg/m), and 5-fluorouracil (750 mg/m×5 d or 1000 mg/m×4 d; continuous infusion) every 3 weeks (DPF) for a planned 2 to 3 cycles. All patients were to receive curative radiotherapy with concurrent systemic therapy. Associations were tested using χ test, and survival estimates were calculated using the Kaplan-Meier method. RESULTS: Most patients (75.4%) were of low SES. Induction DPF was delivered for a median of 2 cycles (range, 1 to 3) and 14% of the patients (n=17) died during induction DPF. After DPF, 38.2% of patients were unable to complete or receive planned definitive therapy. Overall 15.3% of patients died during therapy, and mortality was associated with a Karnofsky performance status <80 (P=0.04). At 2 years the locoregional control was 52.7%, whereas the distant metastases free rate was 72.6%, and the overall survival rate was 34.1%. Low SES patients were less likely to achieve locoregional control (P=0.05) or survive (P=0.08). CONCLUSIONS: In this population of LAHNC patients of low SES with a high tumor burden and poor performance status, use of induction DPF was associated with 15.3% mortality during therapy and precluded 38.2% of patients from initiating or completing planned definitive therapy.

A systematic and evidence-based approach to the management of vertebral metastasis.

Diagnosis and management of vertebral metastasis requires a systematic approach to patient identification as well as selection of appropriate therapy. Rapid identification and prompt intervention in the treatment of malignant epidural spinal cord compression (MESCC) is key to maintaining quality of life. This paper provides a series of tools as well as guidance in selecting effective and evidence-based therapy individualized to the specific patient.

Utility of megavoltage fan-beam CT for treatment planning in a head-and-neck cancer patient with extensive dental fillings undergoing helical tomotherapy.

The purpose of this study was to demonstrate the potential utility of megavoltage fan-beam computed tomography (MV-FBCT) for treatment planning in a patient undergoing helical tomotherapy for nasopharyngeal carcinoma in the presence of extensive dental artifact. A 28-year-old female with locally advanced nasopharyngeal carcinoma presented for radiation therapy. Due to the extensiveness of the dental artifact present in the oral cavity kV-CT scan acquired at simulation, which made treatment planning impossible on tomotherapy planning system, MV-FBCT imaging was obtained using the HI-ART tomotherapy treatment machine, with the patient in the treatment position, and this information was registered with her original kV-CT scan for the purposes of structure delineation, dose calculation, and treatment planning. To validate the feasibility of the MV-FBCT-generated treatment plan, an electron density CT phantom (model 465, Gammex Inc., Middleton, WI) was scanned using MV-FBCT to obtain CT number to density table. Additionally, both a "cheese" phantom (which came with the tomotherapy treatment machine) with 2 inserted ion chambers and a generic phantom called Quasar phantom (Modus Medical Devices Inc., London, ON, Canada) with one inserted chamber were used to confirm dosimetric accuracy. The MV-FBCT could be used to clearly visualize anatomy in the region of the dental artifact and provide sufficient soft-tissue contrast to assist in the delineation of normal tissue structures and fat planes. With the elimination of the dental artifact, the MV-FBCT images allowed more accurate dose calculation by the tomotherapy system. It was confirmed that the phantom material density was determined correctly by the tomotherapy MV-FBCT number to density table. The ion chamber measurements agreed with the calculations from the MV-FBCT generated phantom plan within 2%. MV-FBCT may be useful in radiation treatment planning for nasopharyngeal cancer patients in the setting of extensive dental artifacts.

Late esophageal toxicity after radiation therapy for head and neck cancer.

BACKGROUND: The aim of this study was to determine the incidence of esophageal toxicity after radiation therapy for head and neck cancer. METHODS: The records of 211 patients treated by radiation therapy for head and neck cancer were reviewed to identify those with dysphagia lasting more than 90 days after therapy. Late toxicity criteria established by the Radiation Therapy Oncology Group were used to score the symptoms. RESULTS: The incidence of grade 3+ esophageal toxicity at 3 and 6 months was 30% and 19%, respectively. The rate of gastrotomy-tube dependence at 3 and 6 months was 20% and 11%, respectively. Hypopharyngeal and unknown primary site (p = .01, for both), T4 disease (p = .01), and the use of concurrent chemotherapy (p = .001) were associated with grade 3+ esophageal toxicity and stricture formation. CONCLUSION: A significant proportion of patients exhibit symptoms of esophageal toxicity after radiation therapy for head and neck cancer. Therefore, preventive strategies need further investigation.

Initial clinical experience with helical tomotherapy for head and neck cancer.

BACKGROUND: To report a single-institutional experience with the use of helical tomotherapy (HT)-based intensity-modulated radiotherapy (IMRT) for head and neck cancer. METHODS: Seventy-seven consecutive patients were treated with HT for squamous cell carcinoma of the head and neck to a median dose of 66 Gy (range, 60 to 72 Gy). Megavoltage CT scans were obtained as part of an image-guided registration protocol for patient alignment before each treatment. Concurrent chemotherapy was administered to 48 patients (62%). RESULTS: The 2-year estimates of overall survival, local-regional control, and disease-free survival were 82%, 77%, and 71%, respectively. Spatial evaluation of local-regional failures revealed that 16 of the 18 patients who progressed in the primary site or neck failed in the high-dose planning target volume (PTV). CONCLUSIONS: HT appears to achieve clinical outcomes comparable to contemporary series reporting on IMRT for head and neck cancer.

Prospective study of psychosocial distress among patients undergoing radiotherapy for head and neck cancer.

PURPOSE: To determine the prevalence of psychosocial distress among patients undergoing radiotherapy (RT) for head and neck cancer and to examine the association between depression and anxiety and demographic and medical variables. METHODS AND MATERIALS: A total of 40 patients (25 men and 15 women) with nonmetastatic head and neck cancer were enrolled in this prospective study and underwent RT administered with definitive (24 patients) or postoperative (16 patients) intent. Twenty patients (50%) received concurrent chemotherapy. All patients completed the Hospital Anxiety and Depression Scale and Beck Depression Inventory-II instrument before RT, on the last day of RT, and at the first follow-up visit. The effect of patient-, tumor-, and treatment-related factors on psychosocial distress was analyzed. RESULTS: The prevalence of mild to severe pre-RT depression was 58% and 45% using the Hospital Anxiety and Depression Scale-D and Beck Depression Inventory-II scale, respectively. The prevalence of severe pre-RT anxiety was 7%. The depression levels, as determined by the Hospital Anxiety and Depression Scale and Beck Depression Inventory-II instrument increased significantly during RT and remained elevated at the first follow-up visit (p < 0.001 for both). The variables that were significantly associated with post-RT depression included a greater pre-RT depression level, employment status (working at enrollment), younger age (<55 years), single marital status, and living alone (p < 0.05, for all). CONCLUSION: The results of our study have shown that an alarming number of patients undergoing RT for head and neck cancer have symptoms suggestive of psychosocial distress even before beginning treatment. This proportion increases significantly during RT. Studies investigating the role of antidepressants and/or psychiatric counseling might be warranted in the future.