ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma.

BACKGROUND: Chemotherapy plus radiation treatment is effective in controlling stage IA or IIA nonbulky Hodgkin's lymphoma in 90% of patients but is associated with late treatment-related deaths. Chemotherapy alone may improve survival because it is associated with fewer late deaths. METHODS: We randomly assigned 405 patients with previously untreated stage IA or IIA nonbulky Hodgkin's lymphoma to treatment with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) alone or to treatment with subtotal nodal radiation therapy, with or without ABVD therapy. Patients in the ABVD-only group, both those with a favorable risk profile and those with an unfavorable risk profile, received four to six cycles of ABVD. Among those assigned to subtotal nodal radiation therapy, patients who had a favorable risk profile received subtotal nodal radiation therapy alone and patients with an unfavorable risk profile received two cycles of ABVD plus subtotal nodal radiation therapy. The primary end point was 12-year overall survival. RESULTS: The median length of follow-up was 11.3 years. At 12 years, the rate of overall survival was 94% among those receiving ABVD alone, as compared with 87% among those receiving subtotal nodal radiation therapy (hazard ratio for death with ABVD alone, 0.50; 95% confidence interval [CI], 0.25 to 0.99; P=0.04); the rates of freedom from disease progression were 87% and 92% in the two groups, respectively (hazard ratio for disease progression, 1.91; 95% CI, 0.99 to 3.69; P=0.05); and the rates of event-free survival were 85% and 80%, respectively (hazard ratio for event, 0.88; 95% CI, 0.54 to 1.43; P=0.60). Among the patients randomly assigned to ABVD alone, 6 patients died from Hodgkin's lymphoma or an early treatment complication and 6 died from another cause; among those receiving radiation therapy, 4 deaths were related to Hodgkin's lymphoma or early toxic effects from the treatment and 20 were related to another cause. CONCLUSIONS: Among patients with Hodgkin's lymphoma, ABVD therapy alone, as compared with treatment that included subtotal nodal radiation therapy, was associated with a higher rate of overall survival owing to a lower rate of death from other causes. (Funded by the Canadian Cancer Society and the National Cancer Institute; HD.6 ClinicalTrials.gov number, NCT00002561.).

Conventional Versus Hypofractionated Radiation for High-Risk Prostate Cancer Patients (CHIRP): 24-Month Patient-Reported Outcomes of the Randomized Phase 2 CHIRP Trial.

PURPOSE: In this study, we report the 24-month patient-reported outcomes of the randomized phase 2 CHIRP trial that compared conventional and hypofractionated radiation therapy (RT) in the treatment of high-risk prostate cancer. METHODS AND MATERIALS: Men with high-risk localized prostate cancer were randomized to either conventional (78 Gy/39 fractions) or hypofractionated RT (68 Gy/25 fractions). All patients received pelvic nodal RT and adjuvant androgen deprivation therapy. Quality of life (QoL) data were collected through the expanded prostate cancer index composite and the short-form 12 (SF-12) health-related QoL questionnaire at baseline and at 3, 6, 12, 18, and 24 months posttreatment. We assessed change from baseline to account for differences in baseline comorbidities. Independent t test was used to identify differences between the 2 groups. RESULTS: Ninety-six participants were included in the QoL analysis, 49 in the hypofractionation arm and 47 in the standard fractionation arm. Urinary and sexual scores were similar between the 2 arms at all time points. Bowel bother scores exhibited a consistent trend favoring the standard arm from 3- to 18-months posttreatment and were statistically significant at 12 months (P = .016). SF-12 physical component scores showed a consistent trend favoring the hypofractionation arm from 6- to 18-months posttreatment and were statistically significant at 18 months (P = .017). At 24 months, there were no significant differences in QoL scores between the 2 groups. CONCLUSIONS: At 24 months post-RT, there were no major differences in patient-reported QoL between standard and hypofractionated RT. Early statistically significant differences in bowel bother and SF-12 physical component scores were no longer present at 24 months.

Clinical Outcomes of the CHIRP Trial: A Phase II Prospective Randomized Trial of Conventionally Fractionated Versus Moderately Hypofractionated Prostate and Pelvic Nodal Radiation Therapy in Patients With High-Risk Prostate Cancer.

PURPOSE: Hypofractionated radiation therapy (HFRT) may offer treatment advantages for patients with prostate cancer. However, HFRT may also increase the risk of gastrointestinal (GI) or genitourinary (GU) toxicity compared with conventionally fractionated radiation therapy (CFRT). Several large trials have found that HFRT is well tolerated in mixed risk population studies. Here, we report on a phase II, randomized controlled study conducted to evaluate these endpoints in exclusively high-risk patients with prostate cancer treated with prostate and pelvic nodal radiation. METHODS AND MATERIALS: After giving informed consent, patients with high-risk prostate cancer were randomly assigned to prostate plus pelvic nodal radiation therapy with either HFRT (68 Gy in 25 fractions) or CFRT (78 Gy in 39 fractions) and 18 months of androgen suppression therapy. Toxicity was scored using the Common Terminology Criteria for Adverse Events (version 4.0). Biochemical failure was determined by the Phoenix definition. Patients were analyzed on an intention-to-treat basis. RESULTS: From 2012 to 2018, 111 patients with high-risk prostate cancer were enrolled and 109 patients were treated. The cumulative incidence of grade 2 or higher acute GI toxicity was not significantly different between the arms (HFRT 18.9% vs CFRT 21.8%; P = .812). Similarly, acute GU (HFRT 30.2% vs CFRT 30.9%; P = 1.00), late GI (HFRT 16.0% vs CFRT 10.0%; P = .554), and late GU (HFRT 16.0% vs CFRT 6.0%; P = .200) were not significantly different between the arms. Median follow-up was 38.0 months (4.8-77.8 months). The 3-year biochemical recurrence-free survival was not significantly different between the 2 arms (97.3% for HFRT vs 91.0% for CFRT; P = .606). The 3-year overall survival was 94.8% in the HFRT arm and 100.0% in the CFRT arm (P = .116). CONCLUSIONS: HFRT and CFRT using intensity modulated radiation therapy were both well tolerated for patients with high-risk prostate cancer and resulted in similar 3-year biochemical recurrence-free survival and overall survival.

Assessment of outcomes in surgically staged I/II endometrial adenocarcinoma patients treated with postoperative vaginal vault radiotherapy only.

OBJECTIVE: To examine the efficacy of vaginal vault radiotherapy as adjuvant treatment for patients with high-grade, stage I/II endometrial adenocarcinoma who have been surgically staged. METHODS: A retrospective chart review of 77 women between 1995 and 2006 with high-grade surgically staged I and II endometrial adenocarcinoma, who were treated with postoperative vaginal vault radiotherapy alone, was performed. The primary study end points were recurrence risk and sites of recurrence. The secondary end points were disease-free and overall survival. Kaplan-Meier estimates were calculated for overall and disease-free survival. RESULTS: Seventy-seven women were identified and met inclusion criteria. Sixty-seven (87%) had grade 3 histologic features on final pathologic report. Forty-two patients (55%) were classified as stage IB, having superficial myometrial invasion; 21 (27%) were stage IC, with deep invasion; and 6 (8%) were stage II, involving the cervix. The median follow-up was 80 months (6.6 years). There were 10 recurrences (13.0%), of which 3 were local: 1 involving the vaginal apex; 1, the lower vagina and pelvic sidewall; and 1, the lower vagina. The 5-year recurrence risk was 11.2% and the 5-year survival probability 88.9%. CONCLUSIONS: It seems that for this cohort of 77 patients with surgically staged I and II grade 3 endometrial adenocarcinoma, adjuvant vaginal vault radiotherapy alone leads to acceptable recurrence rates and survival while minimizing morbidity.

The management of inoperable Stage I endometrial cancer using intracavitary brachytherapy alone: a 20-year institutional review.

OBJECTIVE: To review our institution's results with primary low dose rate (LDR) intracavitary brachytherapy using Heyman's capsules for medically inoperable cancer of the endometrium. METHODS: The study was a retrospective review of inoperable early-stage endometrial cancer patients at the Cross Cancer Institute in Edmonton, Canada, treated with primary radiotherapy from January 10, 1986 to July 17, 2006. Forty-four patients with International Federation of Gynaecology and Obstetrics (FIGO) clinical Stage I disease were included in the study. Kaplan-Meier survival analysis was performed to obtain estimates of overall survival (OS), disease-free survival, and disease-specific survival (DSS). Tumor grade was assessed as a potential predictor of OS by comparing survival curves using a log-rank test. RESULTS: The median OS time was 75.5 months (95% confidence interval 55.6-95.3 months). For the entire group, the 5- and 10-year OS was 60.5% and 24.0%, respectively. The 5- and 10-year DSS was 87.7% and 79.7%, respectively. For a subset treated as planned, the 5- and 10-year OS was 54.5% and 34.5%, respectively. The 5- and 10-year DSS was 83.0% and 76.4%, respectively. When stratified by grade, trends in survival analysis are inversely related to grade. Both the trend analysis and the log-rank test were statistically significant at a p<0.05 level. CONCLUSIONS: Our experience with LDR brachytherapy for the treatment of Stage I endometrial cancer is comparable to surgical treatment and to results reported in the literature for high dose rate brachytherapy. Further study that would help define the indications for a primary radiotherapeutic approach in early-stage endometrial cancer may lower current thresholds for recommending primary radiotherapy versus surgery.

National Trends and Dynamic Responses in the Canadian Radiation Oncology Workforce From 1990 to 2018.

PURPOSE: To report radiation oncology (RO) workforce and cancer incidence trends in Canada and explore the relationship between the two. METHODS AND MATERIALS: Canadian radiation oncologist, trainee, and cancer incidence data from 1990 to 2018 were collected from the following publicly accessible administrative and health information databases: Canadian Post-MD Education Registry (1990-2018), Canadian Medical Association Physician Data Centre (1994-2018), Canadian Institute for Health Information/Scott's Medical Database (1990-2017), Canadian Cancer Registry (1990-2017), and Statistics Canada (1990-2017). Descriptive statistics were used to summarize the data. RESULTS: The Canadian RO workforce grew from 240 radiation oncologists in 1990 to 567 in 2018, with the largest growth period from 2005 to 2015 adding 207 radiation oncologists. Regional analyses revealed steady or stepwise growth in all Canadian regions, except in Québec, where the number of radiation oncologists decreased from 86 in 1990 to 57 in 2003 before rising to 139 by 2018. Trainee totals were between 54 and 173 per year with 2 periods of growth (1990-1996 and 2001-2008) and regression (1996-2001 and 2008-2018), signifying trainee supply variability. Female proportions of the workforce and trainees, respectively, rose steadily from 18% to 38% and 28% to 50%, while the workforce proportion with non-Canadian medical degrees decreased from 40% to 26%. Radiation oncologists younger than 40 years increased from 70 to 171, whereas those age 60 years and older decreased from 85 in 1990 to 31 in 2002 and then increased to 108 in 2017. Annual cancer incidence rose steadily from 103,780 to 206,290 cases/year. The annual cancer incidence-to-provider ratio fluctuated (364-475:1) and trended lower with time, and proportional cancer incidence-to-provider ratios varied between 0.7:1 and 1.6:1 in Canada's regions before approaching 1:1. CONCLUSIONS: Our study demonstrates the challenges and successes of managing the Canadian radiation oncologist workforce. These data will inform policy makers and other stakeholders to ensure that the profession meets the current and future needs of Canadian cancer patients.

Assessment of extended-field radiotherapy for stage IIIC endometrial cancer using three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, and helical tomotherapy.

PURPOSE: To perform a dosimetric comparison of three-dimensional conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT), and helical tomotherapy (HT) plans for pelvic and para-aortic RT in postoperative endometrial cancer patients; and to evaluate the integral dose (ID) received by critical structures within the radiation fields. METHODS AND MATERIALS: We selected 10 patients with Stage IIIC endometrial cancer. For each patient, three plans were created with 3D-CRT, IMRT, and HT. The IMRT and HT plans were both optimized to keep the mean dose to the planning target volume (PTV) the same as that with 3D-CRT. The dosimetry and ID for the critical structures were compared. A paired two-tailed Student t test was used for data analysis. RESULTS: Compared with the 3D-CRT plans, the IMRT plans resulted in lower IDs in the organs at risk (OARs), ranging from -3.49% to -17.59%. The HT plans showed a similar result except that the ID for the bowel increased 0.27%. The IMRT and HT plans both increased the IDs to normal tissue (see Table 1 and text for definition), pelvic bone, and spine (range, 3.31-19.7%). The IMRT and HT dosimetry showed superior PTV coverage and better OAR sparing than the 3D-CRT dosimetry. Compared directly with IMRT, HT showed similar PTV coverage, lower Ids, and a decreased dose to most OARs. CONCLUSION: Intensity-modulated RT and HT appear to achieve excellent PTV coverage and better sparing of OARs, but at the expense of increased IDs to normal tissue and skeleton. HT allows for additional improvement in dosimetry and sparing of most OARs.

The relationship between waiting time for radiotherapy and clinical outcomes: a systematic review of the literature.

PURPOSE: To synthesize the direct clinical evidence relating waiting times (WTs) for radiotherapy (RT) to the outcomes of RT. METHODS AND MATERIALS: We did a systematic review of the literature between 1975 and 2005 to identify clinical studies describing the relationship between WTs and outcomes of RT. Only high quality (HQ) studies that had adequately controlled for confounding factors were included in the primary analysis. WTs that had originally been reported as a categorical variable were converted to a continuous variable based on the distribution of WTs in each category. Meta-analyses were done using a fixed-effect model. RESULTS: The systematic review identified 44 relevant studies. Meta-analyses of 20 HQ studies of local control demonstrated a significant increase in the risk of local failure with increasing WT, RRlocal recurrence/month =1.14, 95% Confidence Intervals (CI): 1.09-1.21. For post-operative RT for breast cancer; RRlocal recurrence/month =1.11, 95%CI: 1.04-1.19. For post-operative RT for head and neck cancer, RRlocal recurrenc/month =1.28, 95%CI: 1.08-1.52. For definitive RT for head and neck cancer, RRlocal recurrence/month =1.15, 95%CI: 1.02-1.29. There was little evidence of any association between WTs and the risk of distant metastasis. Meta-analyses of the 6 HQ studies of breast cancer showed RRmetastasis/month =1.04, 95%CI: 0.98-1.09. Meta-analyses of 4 HQ studies of breast cancer showed no significant decrease in survival with increasing WT, RRdeath/month =1.06, 95%CI: 0.97-1.16, but there was a marginally significant decrease in survival in 4 HQ studies of head and neck cancer, RRdeath/month =1.16, 95%CI: 1.02-1.32. CONCLUSIONS: The risk of local recurrence increases with increasing WTs for RT. The increase in local recurrence rate may translate into decreased survival in some clinical situations. WTs for RT should be as short as reasonably achievable.

Twenty-year review of radiotherapy for vaginal cancer: an institutional experience.

OBJECTIVE: To evaluate clinical outcome, prognostic factors and chronic morbidity with radiotherapy for vaginal cancer treatment. MATERIALS AND METHODS: 68 patients with vaginal cancer treated by radical or adjuvant radiotherapy (RT) were selected. Five with rare subtypes of histopathology and 8 with adenocarcinoma were excluded from this study. 76.4% of the remainder had early-stage diseases (stage I: 14, II: 28, III: 9, and IV: 4). The patients in the years from which they were treated were almost evenly distributed (1st 5 years: 13, 2nd: 14, 3rd: 16, and 4th: 12). There were four treatment groups: external beam radiotherapy (EBRT) alone (n=18), brachytherapy (BT) alone (n=4), EBRT and BT (n=30), and surgery plus RT (n=3). RESULTS: Median follow-up was 50.3 months ranging from 3 to 213 months. 5-year overall survival (OS) was 55.6%, disease-specific survival (DSS) was 77.3%, disease-free survival was 74.2%, and local control was 87.7%. Independent prognostic factors for DSS and OS were tumor stage, site and size (p<0.05). Late radiation toxicity was minimal in the bladder (4.6%) and bowel (4.6%). Vaginal morbidity was observed in 35 patients (63.6%). It was lowest in the BT alone (0%), and highest in the EBRT and BT group (82.1%), especially for those received more than 70 Gy (p=0.05, Odds ratio=4.64, 95% confidence interval: 1.01-21.65). CONCLUSION: This retrospective review suggested that tumor stage, site, and size were important prognostic factors in patients with vaginal cancer. Higher radiation dose was associated with more frequent vaginal toxicity.

A young woman with distant recurrent metastatic primary vaginal carcinoma salvaged with radical radiotherapy.

The incidence of distant recurrent metastatic primary vaginal carcinoma is rare. The prognosis in such cases is poor, with cure being extremely rare. We report the case of a young woman, with distant recurrent metastatic primary vaginal carcinoma in which the patient remains disease-free 5 years after completing salvage radical radiotherapy. The clinical management of recurrent metastatic primary vaginal carcinoma must be tailored to the site of recurrence and the patient's performance status. Complete clinical remission and long-term survival without evidence of disease may be achieved in rare cases with radical radiotherapy.

Correlates of exercise motivation and behavior in a population-based sample of endometrial cancer survivors: an application of the Theory of Planned Behavior.

BACKGROUND: Despite evidence of the benefits of exercise in cancer survivors, exercise participation rates tend to decline after treatments. Few studies have examined the determinants of exercise in less common cancer sites. In this study, we examined medical, demographic, and social cognitive correlates of exercise in endometrial cancer survivors using the Theory of Planned Behavior (TPB). METHODS: A mailed survey was completed by 354 endometrial cancer survivors (1 to 10 years postdiagnosis) residing in Alberta, Canada. The study was cross-sectional. Exercise behavior was assessed using the Godin Leisure Time Exercise Questionnaire and the TPB constructs were assessed with standard self-report scales. Multiple regression analyses were used to determine the independent associations of the TPB constructs with intention and behavior. RESULTS: Chi-square analyses indicated that marital status (p = .003), income level (p = .013), and body mass index (BMI) (p = .020) were associated with exercise. The TPB explained 34.1% of the variance in exercise behavior with intention (beta = .38, p < .001) and self-efficacy (beta = .18, p = .029) being independent correlates. For intention, 38.3% of the variance was explained by the TPB with self-efficacy (beta = .34, p < .001) and affective attitude (beta = .30, p < .001) being the independent correlates. The TPB mediated the associations of marital status and BMI with exercise but not income level. Age and BMI moderated the associations of the TPB with intention and behavior. CONCLUSION: The TPB may be a useful framework for understanding exercise in endometrial cancer survivors. Exercise behavior change interventions based on the TPB should be tested in this growing population.

Radiotherapy in the Multidisciplinary Management of Adenomyoepithelioma of the Breast with an Axillary Lymph Node Metastasis: A Case Report and Review of the Literature.

We describe a case of aggressive adenomyoepithelioma (AME) of the breast with a lymph node metastasis. A 63-year-old female presented with a fluctuating breast mass and clinically palpable lymph nodes. The patient underwent excisional biopsy followed by mastectomy with lymph node dissection and adjuvant radiotherapy (RT). Clinical behavior of both benign and malignant AME is described with the review of the literature and treatment recommendations.

Late Toxicity and Outcomes in High-risk Prostate Cancer Patients Treated With Hypofractionated IMRT and Long-term Androgen Suppression Treatment.

OBJECTIVE: To assess late toxicity and outcomes in high-risk prostate cancer patients treated with hypofractionated radiation treatment with androgen suppression therapy. METHODS: Sixty high-risk prostate cancer patients were enrolled. IMRT prescription was 68 Gy/25 fractions (2.7 Gy/fraction) to the prostate and proximal seminal vesicles (SV). The pelvic lymph nodes (PLN) and distal SV concurrently received 45 Gy/25 fractions (1.8 Gy/fraction). The patients were treated with helical TomoTherapy-based IMRT and underwent daily megavoltage CT image-guided verification before each treatment. RTOG Toxicity scores were recorded for a 5-year period. RESULTS: Sixty patients completed RT with median follow-up of 63 months (range, 7 to 80 mo).At 5 years follow-up timepoint: Grade (G)2 and G3 late genitourinary toxicity was experienced in 7 (17.0%) and 1 (2.44%), respectively; gastrointestinal G2 as highest toxicity recorded in only 1 (2.44%) patient. There was no G3 gastrointestinal toxicity recorded at this timepoint.With 63-month median follow-up (mean of 65.41±1.72 mo), the 5-year overall survival was 86.67%; 5 years freedom from biochemical failure was 91.67% and freedom from clinical failure was 96.67%. CONCLUSIONS: Dose escalation and hypofractionated radiation treatment with IMRT treating the prostate and proximal SV concurrently with the pelvic lymph nodes and distal SV and long-term androgen suppression therapy is well tolerated with respect to acute and late toxicity with 5-year actuarial overall survival 86.67%, freedom from biochemical failure 91.38%, and freedom from clinical failure 96.67%. Longer follow-up will provide more information on 10-year survival outcomes.

Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group.

PURPOSE: We report results of a randomized trial comparing ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) chemotherapy alone with treatment that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma. PATIENTS AND METHODS: Patients with nonbulky clinical stage I to IIA Hodgkin's lymphoma were stratified into favorable and unfavorable risk cohorts. Patients allocated to radiation-containing therapy received subtotal nodal radiation if favorable risk or combined-modality therapy if unfavorable risk. Patients allocated to ABVD received four to six treatment cycles. RESULTS: We evaluated 399 patients. Median follow-up is 4.2 years. In comparison with ABVD alone, 5-year freedom from disease progression is superior in patients allocated to radiation therapy (P = .006; 93% v 87%); no differences in event-free survival (P = .06; 88% v 86%) or overall survival (P = .4; 94% v 96%) were detected. In a subset analyses comparing patients stratified into the unfavorable cohort, freedom from disease progression was superior in patients allocated to combined-modality treatment (P = .004; 95% v 88%); no difference in overall survival was detected (P = .3; 92% v 95%). Of 15 deaths observed, nine were attributed to causes other than Hodgkin's lymphoma or acute treatment-related toxicity. CONCLUSION: In patients with limited-stage Hodgkin's lymphoma, no difference in overall survival was detected between patients randomly assigned to receive treatment that includes radiation therapy or ABVD alone. Although 5-year freedom from disease progression was superior in patients receiving radiation therapy, this advantage is offset by deaths due to causes other than progressive Hodgkin's lymphoma or acute treatment-related toxicity.

mtDNA mutations in invasive cervix tumors: a retrospective analysis.

We tested whether mtDNA mutations are associated with poor outcome in patients with invasive cervix cancer. Tumor samples were banked more than 10 years ago from women with diagnoses of invasive cervix cancer. Automated techniques were used to determine the sequence of the mtDNA-encoded Complex I subunits. Approximately one-third of all tumors had multiple mtDNA sequence alterations. Both univariate and multivariate analysis of the 10 years survival probability showed that the 10 years survival of patients whose tumors had eight or more nucleotide substitutions was significantly worse (P<0.0063 and P<0.012, respectively). The log-rank test also found a significant difference in overall survival (P<0.003). These results suggest that multiple mtDNA mutations are an independent marker of poor prognosis, and that prospective clinical trials that incorporate analysis of mitochondrial genetic alterations in cervix cancer are warranted.

Exercise preferences of endometrial cancer survivors: a population-based study.

Exercise has gained recognition as an effective supportive care intervention for cancer survivors, yet participation rates are low. Knowledge of the specific exercise counseling and programming preferences of cancer survivors may be useful for designing effective interventions. In this study, we examined the exercise preferences of 386 endometrial cancer survivors. Participants completed a questionnaire that included measures of past exercise behavior, exercise preferences, and medical and demographic information. Some key findings were as follows: (a) 76.9% of participants said they were interested or might be interested in doing an exercise program and (b) 81.7% felt they were able or likely able to actually do an exercise program. Participants also indicated that walking was their preferred activity (68.6%) and moderate exercise was their preferred intensity (61.1%). Logistic regression analyses showed that meeting public health guidelines for exercise, being overweight or obese, receiving adjuvant treatment, months since diagnosis, income, marital status, and level of education all influenced exercise preferences. These results suggest that endometrial cancer survivors have unique exercise preferences that are moderated by a number of demographic and medical variables. These findings may have implications for the design and implementation of clinical and population-based exercise interventions for endometrial cancer survivors.

Radiation therapy quality-of-care indicators for locally advanced cervical cancer: A consensus guideline.

PURPOSE: Radiation therapy plays an important curative role for patients with locally advanced cervical cancer (LACC). There are no standards to define best practice. The purpose of this study was to develop a suite of radiation therapy key quality-of-care indicators (KQIs) for the curative management of LACC based on expert consensus. METHODS AND MATERIALS: A modified Delphi method was used after identifying candidate KQIs. Round 1 involved surveying all Canadian gynecology radiation oncologists. The current and anticipated future (5 years) importance and current achievability of each KQI was ranked. Round 2 consisted of a facilitated face-to-face meeting with a smaller expert panel to discuss, revise, and develop consensus on the KQIs. RESULTS: The literature review identified 83 candidate KQIs. Survey response was 71%. Round 2 yielded a final suite of 40 KQIs in the following categories: pretreatment assessment, external beam radiation therapy, brachytherapy, follow-up, and expertise/workload. A prominent theme was the importance of having KQIs to measure the current state, evolution, and future uptake of magnetic resonance-guided brachytherapy. CONCLUSIONS: To our knowledge, this is the first study establishing radiation therapy KQIs in LACC based on expert consensus. These KQIs should be used to guide programmatic direction and resource allocation to assure consistent and optimal patient care.

Use of a tissue expander to protect small bowel during radiotherapy in a cervical cancer patient with severe Crohn's disease.

•Inflammatory bowel disease increases the risk of radiation enteritis.•Tissue expanders displace bowel from the radiation field.•Thromboembolism and fistulae may be risks associated with tissue expander placement.A Vicryl mesh hammock may prevent bowel from entering the radiation field.

Use of bladder dose points for assessment of the spatial dose distribution in the posterior bladder wall in cervical cancer brachytherapy and the impact of applicator position.

PURPOSE: To validate the feasibility and use of dose points to characterize the bladder wall dose distribution and investigate potential impact of the applicator position in cervical cancer brachytherapy. METHODS AND MATERIALS: One hundred twenty-eight optimized MRI plans were evaluated. The International Commission of Radiation Units and Measurements (ICRU-38) point doses (B(ICRU)), surrogate for bladder base doses, were compared with D(2cc). Vaginal source to superior-anterior border of the symphysis distances were measured and compared within two groups, namely Group 1-B(ICRU)/D(2cc) ≥1 and Group 2-B(ICRU)/D(2cc) <1. Additionally, points at 1.5 and 2 cm cranial to the B(ICRU), parallel to the tandem and the body axis were analyzed. RESULTS: Thirty-seven percent of the patients had the ratio B(ICRU)/D(2cc) of 1 or higher, with the 2cc subvolume at the bladder base (Group 1). In 63%, BICRU/D2cc ratio was lower than 1 and the 2cc, cranial to the bladder base (Group 2). Median vaginal source-to-superior-anterior border of the symphysis line distance was -2 cm (range, -3.7 to +1.2 cm) in Group 1 and +1.8 cm (range, -2 to +4.8 cm) in Group 2 (+ cranial/- caudal direction). There was a high correlation between vaginal sources near the symphysis and the 2cc subvolume at the bladder base. The additional points provided no added value. CONCLUSIONS: Location of the 2cc subvolume varies in cervical cancer brachytherapy. Maximum doses are at the bladder base if vaginal sources are also in the vicinity of the bladder base indicated by B(ICRU)/D(2cc) ratio of 1 or higher. Such variation should be considered in dose-effect analyses and intercomparisons, as the same D(2cc) at different bladder locations may correlate with different morbidity profiles and severity Reporting D(2cc) and B(ICRU) doses together therefore remains essential.

Practically achievable maximum high-risk clinical target volume doses in MRI-guided intracavitary brachytherapy for cervical cancer: a planning study.

PURPOSE: To explore maximum high-risk clinical target volume (HR-CTV) doses that can be practically achieved when organs at risk (OARs; bladder, rectum, and sigmoid) doses are allowed to equal current recommended thresholds in MRI-based intracavitary brachytherapy (BT) planning for cervical cancer. METHODS AND MATERIALS: Planning MRI sets were retrieved for 21 patients who received pulsed-dose-rate BT boost. Plans were generated using manual optimization (MO) by adjusting dwell positions and times to obtain the prescribed HR-CTV isodose that includes 90% of target (D90) coverage of 35 Gy while limiting OAR doses to below recommended tolerances (prescribed dose target [TGT] plans). Additional planning was performed with automatic volume optimization (VO) to evaluate target coverage relative to the MO plans. The MO and VO approaches were then applied with the objective of obtaining the highest possible HR-CTV coverage when OAR doses were allowed to equal threshold tolerance values (maximized [MAX] plans). A two-tailed paired t test was performed to determine the statistical significance of the results; significance level set at p < 0.013. RESULTS: MO and VO planning techniques could conform HR-CTV D90 to the prescribed dose quite similarly for TGT plans. Using the MAX approach, the HR-CTV D90 could be increased by 30% and 37% for MO and VO, respectively, without exceeding OAR thresholds. Sigmoid and often rectum were the dose-limiting structures during MAX planning. CONCLUSIONS: Simple differences in the approach to volumetric MRI-based cervix BT treatment planning can impact HR-CTV D90. Consequently, dose escalation for MRI-guided cervix BT appears feasible in this manner should clinical circumstances warrant.