Virtual Reality-Based Education for Patients Undergoing Radiation Therapy.

We built a virtual reality (VR) application that runs on a commercially available standalone VR headset that allows patients to view a virtual simulation of themselves receiving radiotherapy. The purpose of this study was to determine if this experience can improve patient understanding of radiotherapy and/or reduce patient anxiety. We created software that reads data from our clinical treatment planning system and renders the plan on a life-size "virtual linear accelerator." The patient's CT simulation data is converted into a 3D translucent virtual human shown lying on the treatment table while visible yellow radiation beams are delivered to the target volumes in the patient. We conducted a prospective study to determine if showing patients their radiotherapy plan in VR improves patient education and/or reduces anxiety about treatment. A total of 43 patients were enrolled. The most common plans were 3D breast tangents and intensity-modulated radiotherapy prostate plans. Patients were administered pre- and post-experience questionnaires. Thirty-two patients (74%) indicated that they "strongly agree" that the VR session gave them a better understanding of how radiotherapy will be used to treat their cancer. Of the 21 patients who expressed any anxiety about radiotherapy beforehand, 12 (57%) said that the VR session helped decrease their anxiety about undergoing radiotherapy. In our single-institution, single-arm prospective patient study, we found that the majority of patients reported that the personalized VR experience was educational and can reduce anxiety. VR technology has potential to be a powerful adjunctive educational tool for cancer patients about to undergo radiotherapy.

Nomogram for predicting the benefit of neoadjuvant chemoradiotherapy for patients with esophageal cancer: a SEER-Medicare analysis.

BACKGROUND: The survival impact of neoadjuvant chemoradiotherapy (CRT) on esophageal cancer remains difficult to establish for specific patients. The aim of the current study was to create a Web-based prediction tool providing individualized survival projections based on tumor and treatment data. METHODS: Patients diagnosed with esophageal cancer between 1997 and 2005 were selected from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The covariates analyzed were sex, T and N classification, histology, total number of lymph nodes examined, and treatment with esophagectomy or CRT followed by esophagectomy. After propensity score weighting, a log-logistic regression model for overall survival was selected based on the Akaike information criterion. RESULTS: A total of 824 patients with esophageal cancer who were treated with esophagectomy or trimodal therapy met the selection criteria. On multivariate analysis, age, sex, T and N classification, number of lymph nodes examined, treatment, and histology were found to be significantly associated with overall survival and were included in the regression analysis. Preoperative staging data and final surgical margin status were not available within the SEER-Medicare data set and therefore were not included. The model predicted that patients with T4 or lymph node disease benefitted from CRT. The internally validated concordance index was 0.72. CONCLUSIONS: The SEER-Medicare database of patients with esophageal cancer can be used to produce a survival prediction tool that: 1) serves as a counseling and decision aid to patients and 2) assists in risk modeling. Patients with T4 or lymph node disease appeared to benefit from CRT. This nomogram may underestimate the benefit of CRT due to its variable downstaging effect on pathologic stage. It is available at skynet.ohsu.edu/nomograms.

Smartphone-based augmented reality patient education in radiation oncology.

We built an augmented reality (AR) patient education application for portable iOS and Android devices that allows patients to view a virtual simulation of themselves receiving radiation treatment. We created software that reads data from the clinical treatment planning system and renders the patient's actual radiotherapy plan in AR on a tablet or smartphone. The patient's CT simulation data are converted into a 3D translucent virtual human shown being treated with visible radiation beams from a virtual linear accelerator. We conducted a patient study to determine if showing patients this AR simulation improves patient understanding of radiotherapy and/or reduces anxiety about treatment. A total of 75 patients completed this study. The most common plans were 3D breast tangents and intensity modulated radiotherapy lung plans. Patients were administered questionnaires both before and after their AR viewing experience. After their AR viewing, 95% of patients indicated that they had a better understanding of how radiotherapy will be used to treat their cancer. Of the 35 patients who expressed anxiety about radiotherapy beforehand, 21 (60%) indicated that they had decreased anxiety after the AR session. In our single-arm prospective patient study, we found that this simplified low-cost tablet-based personalized AR simulation can be a helpful educational tool for cancer patients undergoing radiotherapy.

Chemoradiotherapy before and after surgery for locally advanced esophageal cancer: a SEER-Medicare analysis.

PURPOSE: The optimal combination and timing of therapy for esophageal cancer remains controversial. The Surveillance, Epidemiology, and End Results (SEER)-Medicare registry was used to assess neoadjuvant and adjuvant therapy. METHODS: Patients diagnosed with nonmetastatic T3+ or N1+ esophageal adenocarcinoma (ACA) or squamous cell carcinoma (SCC) from 1995 to 2002 who underwent surgical resection within 6 months of diagnosis were studied. Medicare data defined preoperative chemoradiotherapy (preCRT), preoperative radiotherapy (preRT), postoperative CRT (postCRT), chemotherapy and surgery (CT + S), and surgery alone. RESULTS: Of 419 eligible patients, 126 received preCRT, 55 preRT, 40 postCRT, 29 CT + S, and 169 surgery alone. PreCRT yielded median overall survival (OS) of 37 months, greater than surgery alone (17 months, p = 0.002) and postCRT (17 months, p = 0.06). PreRT (20 months, p = 0.20), postCRT (p = 0.88), and CT + S (20 months, p = 0.42) were not associated with OS benefit versus surgery alone. For SCC, preCRT improved survival versus surgery alone (p = 0.01), with a trend for ACA (p = 0.07). ACA (22 months) had greater OS than SCC (17 months) (p = 0.03). ACA, younger age, and married status were associated with increased OS. Adjusting for these, preCRT had longer OS versus surgery alone (p = 0.02) and postCRT (p = 0.03). Chemotherapy agents and surgical approach did not affect OS. CONCLUSIONS: In the SEER-Medicare cohort, preCRT significantly improved survival versus surgery alone and postCRT for locally advanced esophageal cancer, particularly for SCC. PreRT, postCRT, and CT + S were not associated with longer survival.

An interactive tool for individualized estimation of conditional survival in rectal cancer.

BACKGROUND: For rectal cancer patients who have already survived a period of time after diagnosis, survival probability changes and is more accurately depicted by conditional survival. The specific aim of this study was to develop an interactive tool for individualized estimation of changing prognosis for rectal cancer patients. METHODS: A multivariate Cox proportional hazards (CPH) survival model was constructed using data from rectal cancer patients diagnosed from 1994 to 2003 from the Surveillance, Epidemiology, and End Results (SEER) database. Age, race, sex, and stage were used as covariates in the survival prediction model. The primary outcome variable was overall survival conditional on having survived up to 5 years from diagnosis. RESULTS: Data from 42,830 rectal cancer patients met the inclusion criteria. The multivariate CPH model showed age, race, sex, and stage as significant independent predictors of survival. The survival prediction model demonstrated good calibration and discrimination, with a bootstrap-corrected concordance index of 0.75. A web-based prediction tool was built from this regression model that can compute individualized estimates of changing prognosis over time. CONCLUSIONS: An interactive prediction modeling tool can estimate prognosis for rectal cancer patients who have already survived a period of time after diagnosis and treatment. Having more accurate prognostic information can empower both patients and clinicians to be able to make more appropriate decisions regarding follow-up, surveillance testing, and future treatment.

Relative lack of conditional survival improvement in young adults with cancer.

Cancer prognosis is usually reported in terms of survival from time of diagnosis. For patients surviving a period of time after diagnosis, conditional survival (CS) accounts for changing risk over time. This report provides information on how CS in cancer patients changes as a function of age at diagnosis. Using data from the US Surveillance, Epidemiology and End Results database, we examined survival for patients diagnosed between 1973 and 2002. The average annual percent change (AAPC) in CS during the first 5 years after diagnosis was evaluated for the 14 most common cancers occurring in young adults, defined as 15- to 39-year-olds, and how they compared with cancers that are more common in older and younger patients. For all cancers, young adult patients had less CS improvement over time than younger or older patients, and this difference was most pronounced in those aged 20 to 29 years (45% below the mean). Eleven of the 14 most common cancers in 15- to 39-year-olds either had a lower CS improvement after diagnosis than either younger or older patients, or than just the older patients. Young adults with leukemia had the greatest improvement in CS over time. In conclusion, young adults with cancer have not enjoyed the same improvement in CS over time compared with other age groups. Explanations for this deficit include the biologic nature of the type of cancers in young adults and less effective therapies for patients in the age group. Regardless of the reasons, the deficit is yet another challenge faced by young adult patients that merits further study.

Effect of body mass index on shifts in ultrasound-based image-guided intensity-modulated radiation therapy for abdominal malignancies.

BACKGROUND AND PURPOSE: We investigated whether corrective shifts determined by daily ultrasound-based image-guidance correlate with body mass index (BMI) of patients treated with image-guided intensity-modulated radiation therapy (IG-IMRT) for abdominal malignancies. The utility of daily image-guidance, particularly for patients with BMI>25.0, is examined. MATERIALS AND METHODS: Total 3162 ultrasound-directed shifts were performed in 86 patients. Direction and magnitude of shifts were correlated with pretreatment BMI. Bivariate statistical analysis and analysis of set-up correction data were performed using systematic and random error calculations. RESULTS: Total 2040 daily alignments were performed. Average 3D vector of set-up correction for all patients was 12.1mm/fraction. Directional and absolute shifts and 3D vector length were significantly different between BMI cohorts. 3D displacement averaged 4.9 mm/fraction and 6.8mm/fraction for BMI < or = 25.0 and BMI>25.0, respectively. Systematic error in all axes and 3D vector was significantly greater for BMI>25.0. Differences in random error were not statistically significant. CONCLUSIONS: Set-up corrections derived from daily ultrasound-based IG-IMRT of abdominal tumors correlated with BMI. Daily image-guidance may improve precision of IMRT delivery with benefits assessed for the entire population, particularly patients with increased habitus. Requisite PTV margins suggested in the absence of daily image-guidance are significantly greater in patients with BMI>25.0.

Increased vulnerability of the spinal cord to radiation or intrathecal chemotherapy during adolescence: A report from the Children's Oncology Group.

PURPOSE: To assess the rate of spinal cord toxicity in adolescents resulting from chemoradiotherapy of parameningeal sarcoma. METHODS AND MATERIALS: Of 152 patients with parameningeal sarcoma treated per the Intergroup Rhabdomyosarcoma Study Group protocol from 1977 through 1989, eight developed paralyzing ascending myelitis after intrathecal chemotherapy with cytosine arabinoside, methotrexate, and hydrocortisone administered during and after radiation therapy to volumes that included part of the spinal cord. The eight cases include three not previously published. RESULTS: Of eight patients who developed CNS toxicity after intrathecal chemotherapy and radiotherapy for parameningeal rhabdomyosarcoma, all but one were between 13 and 18 years of age when treated. This severe toxicity occurred in one quarter of 28 adolescents treated with the regimen in comparison with one of 123 children 12 years of age or less (P < 0.0001), a rate that was as much as 30 times higher in the adolescents. Lengthening of the spinal cord during the pubertal growth spurt may account for the apparent increased vulnerability. CONCLUSIONS: Chemoradiotoxicity-associated spinal cord injury appears to be more likely to occur in adolescents than in younger or older ages. This observation appears to reverse a conventional wisdom in which the central nervous system is thought to become more resistant to the neurotoxic effects of chemoradiotherapy as it matures.

Conditional survival in ovarian cancer: results from the SEER dataset 1988-2001.

OBJECTIVES: Survival statistics for patients with ovarian cancer are typically reported in terms of survival from time of diagnosis. For patients who have survived a period of time since diagnosis, however, conditional survival (CS) is a more clinically relevant measure, as it accounts for the changes in risk over time. The purpose of this study was to estimate CS for ovarian cancer patients through analysis of large-scale cancer registry data. METHODS: Ovarian cancer cases were extracted from the Surveillance, Epidemiology, and End Results (SEER 17) database from the National Cancer Institute (NCI) for patients diagnosed between 1988-2001. Five-year relative CS calculations were performed with stratification by age, race, stage, histology, and grade for patients who had already survived up to 5 years from diagnosis. RESULTS: The 5-year overall relative CS improved over time for up to 5 years after diagnosis for ovarian cancer patients. The largest gains in CS over time were seen for patients with advanced stage disease, poor grade, and serous and undifferentiated epithelioid histologies. For patients with stage IV disease, 5-year CS more than tripled over the first 5 years of surveillance (17%-56%). Among histological types, patients with undifferentiated epithelioid histology saw 5-year CS rise from 29% at diagnosis to 84% after 5 years. CONCLUSIONS: Prognosis improves over time for almost all groups of ovarian cancer patients. For ovarian cancer survivors, CS provides a more relevant measure of prognosis than conventional survival estimates that are made at the time of diagnosis.

Intensity-modulated Radiosurgery for patients with brain metastases: a mature outcomes analysis.

The purpose of this study was to evaluate the outcomes of patients with brain metastases treated by tomotherapeutic Intensity-modulated Radiosurgery (IMRS). Using retrospective chart review, we analyzed the outcomes of 78 patients (age 33-83 years, median 57 years) who underwent 111 sessions of IMRS (1 to 7 sessions per patient, median 1) for brain metastases (1 to 4 targets per IMRS session, median 1) treated between 2000 and 2005 using a serial tomotherapeutic intensity-modulated radiotherapy treatment (IMRT) planning and delivery system (Peacock, Nomos Corp., Cranberry Township, PA). Treatment planning was performed using an inverse treatment planning optimization algorithm that was optimized for IMRS. A median prescription dose of 15 Gy in combination with WBI, and median 20 Gy for IMRS alone was delivered using 2-4 couch angles over 4-24 rotational arcs. Overall survival was calculated using Kaplan-Meier analysis. To determine the effects of prognostic variables on survival, univariate and multivariate analyses using proportional hazards were performed to assess the effects of age, tumor size, the combination with whole brain irradiation, presence of multiple brain metastases, and presence of extracranial disease. The median overall survival was 6.5 months (95% CI, 5.5-7.9). One- and two-year survival rates were 24% and 10%. In multivariate analyses, age greater than 60 years was the only statistically significant variable that affected survival (hazard rate 1.29, p=0.049). We conclude that tomotherapeutic IMRS is safe and effective to treat patients with brain metastases.

A cost-benefit analysis of electronic medical records in primary care.

Electronic medical record systems improve the quality of patient care and decrease medical errors, but their financial effects have not been as well documented. The purpose of this study was to estimate the net financial benefit or cost of implementing electronic medical record systems in primary care. We performed a cost-benefit study to analyze the financial effects of electronic medical record systems in ambulatory primary care settings from the perspective of the health care organization. Data were obtained from studies at our institution and from the published literature. The reference strategy for comparisons was the traditional paper-based medical record. The primary outcome measure was the net financial benefit or cost per primary care physician for a 5-year period. The estimated net benefit from using an electronic medical record for a 5-year period was 86,400 US dollars per provider. Benefits accrue primarily from savings in drug expenditures, improved utilization of radiology tests, better capture of charges, and decreased billing errors. In one-way sensitivity analyses, the model was most sensitive to the proportion of patients whose care was capitated; the net benefit varied from a low of 8400 US dollars to a high of 140,100 US dollars . A five-way sensitivity analysis with the most pessimistic and optimistic assumptions showed results ranging from a 2300 US dollars net cost to a 330,900 US dollars net benefit. Implementation of an electronic medical record system in primary care can result in a positive financial return on investment to the health care organization. The magnitude of the return is sensitive to several key factors.

Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool.

BACKGROUND: Problem lists are fundamental to electronic medical records (EMRs). However, obtaining an appropriate problem list dictionary is difficult, and getting users to code their problems at the time of data entry can be challenging. OBJECTIVE: To develop a problem list dictionary and search algorithm for an EMR system and evaluate its use. METHODS: We developed a problem list dictionary and lookup tool and implemented it in several EMR systems. A sample of 10,000 problem entries was reviewed from each system to assess overall coding rates. We also performed a manual review of a subset of entries to determine the appropriateness of coded entries, and to assess the reasons other entries were left uncoded. RESULTS: The overall coding rate varied significantly between different EMR implementations (63-79%). Coded entries were virtually always appropriate (99%). The most frequent reasons for uncoded entries were due to user interface failures (44-45%), insufficient dictionary coverage (20-32%), and non-problem entries (10-12%). CONCLUSION: The problem list dictionary and search algorithm has achieved a good coding rate, but the rate is dependent on the specific user interface implementation. Problem coding is essential for providing clinical decision support, and improving usability should result in better coding rates.

Defining the role of adjuvant therapy: cholangiocarcinoma and gall bladder cancer.

Biliary tract cancers are a rare subgroup of malignancies that include gall bladder carcinoma and cholangiocarcinoma. They generally carry a poor prognosis based on the advanced nature of disease at presentation and overall treatment refractoriness. Surgical resection remains the optimal treatment for long-term survival, with consideration of neoadjuvant or adjuvant therapies. In this review, we summarize the role of adjuvant treatments including radiation therapy, chemotherapy, and concurrent chemoradiation with the existing clinical evidence for each treatment decision. Given the rarity of these tumors, the evidence provided is based largely on retrospective studies, Surveillance, Epidemiological, and End Results (SEER) database inquiries, single- or multi-institutional prospective studies, and a meta-analysis of adjuvant therapy studies. Currently, there is no adjuvant therapy that has been agreed upon as a standard of care. Results from prospective, multi-institutional phase II and III trials are awaited, along with advances in molecular targeted therapies and radiation techniques, which will better define treatment standards and improve outcomes in this group of diseases.

An oral cavity carcinoma nomogram to predict benefit of adjuvant radiotherapy.

IMPORTANCE: After surgical resection for oral cavity squamous cell carcinoma, adjuvant radiotherapy may be recommended for patients at higher risk for locoregional recurrence, but it can be difficult to predict whether a particular patient will benefit. OBJECTIVE: To construct a model to predict which patients with oral cavity squamous cell carcinoma would benefit from adjuvant radiotherapy. DESIGN AND SETTING: We constructed several types of survival models using a set of 979 patients with oral cavity squamous cell carcinoma. Covariates were age, sex, tobacco use, stage, grade, margins, and subsite. The best performing model was externally validated on a set of 431 patients. PARTICIPANTS: The model was based on a set of 979 patients with oral cavity squamous cell carcinoma, including 563 from Memorial Sloan Kettering Cancer Center, New York, New York, and 416 from the Hospital AC Camargo, São Paulo, Brazil. The validation set consisted of 431 patients from Princess Margaret Hospital, Toronto, Ontario, Canada. MAIN OUTCOME AND MEASURE: The primary outcome measure of interest was locoregional recurrence-free survival. RESULTS: The lognormal model showed the best performance per the Akaike information criterion. An online nomogram was built from this model that estimates locoregional failure-free survival with and without postoperative radiotherapy. CONCLUSIONS AND RELEVANCE: A web-based nomogram can be used as a decision aid for adjuvant treatment decisions for patients with oral cavity squamous cell carcinoma.

Individualized estimation of conditional survival for patients with head and neck cancer.

Survival for cancer patients is usually only reported as survival from time of diagnosis. For patients who survive 1 or more years after diagnosis, however, survival probability changes over time and is more accurately depicted by conditional survival. The specific aim of this project was to build a survival regression model and Web-based tool to make individualized estimates of conditional survival for patients with head and neck cancer based on tumor and patient characteristics. Using data from the Surveillance, Epidemiology, and End Results (SEER) database, a prediction modeling tool was built that can estimate prognosis for patients with head and neck cancer who have already survived a period of time after diagnosis. Having more accurate prognostic information may empower both patients and clinicians to make more appropriate decisions regarding follow-up, surveillance testing, and future treatment.

Nomogram for predicting the benefit of adjuvant chemoradiotherapy for resected gallbladder cancer.

PURPOSE: Although adjuvant chemoradiotherapy for resected gallbladder cancer may improve survival for some patients, identifying which patients will benefit remains challenging because of the rarity of this disease. The specific aim of this study was to create a decision aid to help make individualized estimates of the potential survival benefit of adjuvant chemoradiotherapy for patients with resected gallbladder cancer. METHODS: Patients with resected gallbladder cancer were selected from the Surveillance, Epidemiology, and End Results (SEER) -Medicare database who were diagnosed between 1995 and 2005. Covariates included age, race, sex, stage, and receipt of adjuvant chemotherapy or chemoradiotherapy (CRT). Propensity score weighting was used to balance covariates between treated and untreated groups. Several types of multivariate survival regression models were constructed and compared, including Cox proportional hazards, Weibull, exponential, log-logistic, and lognormal models. Model performance was compared using the Akaike information criterion. The primary end point was overall survival with or without adjuvant chemotherapy or CRT. RESULTS: A total of 1,137 patients met the inclusion criteria for the study. The lognormal survival model showed the best performance. A Web browser-based nomogram was built from this model to make individualized estimates of survival. The model predicts that certain subsets of patients with at least T2 or N1 disease will gain a survival benefit from adjuvant CRT, and the magnitude of benefit for an individual patient can vary. CONCLUSION: A nomogram built from a parametric survival model from the SEER-Medicare database can be used as a decision aid to predict which gallbladder patients may benefit from adjuvant CRT.

Prospective randomized double-blind pilot study of site-specific consensus atlas implementation for rectal cancer target volume delineation in the cooperative group setting.

PURPOSE: Variations in target volume delineation represent a significant hurdle in clinical trials involving conformal radiotherapy. We sought to determine the effect of a consensus guideline-based visual atlas on contouring the target volumes. METHODS AND MATERIALS: A representative case was contoured (Scan 1) by 14 physician observers and a reference expert with and without target volume delineation instructions derived from a proposed rectal cancer clinical trial involving conformal radiotherapy. The gross tumor volume (GTV), and two clinical target volumes (CTVA, including the internal iliac, presacral, and perirectal nodes, and CTVB, which included the external iliac nodes) were contoured. The observers were randomly assigned to receipt (Group A) or nonreceipt (Group B) of a consensus guideline and atlas for anorectal cancers and then instructed to recontour the same case/images (Scan 2). Observer variation was analyzed volumetrically using the conformation number (CN, where CN = 1 equals total agreement). RESULTS: Of 14 evaluable contour sets (1 expert and 7 Group A and 6 Group B observers), greater agreement was found for the GTV (mean CN, 0.75) than for the CTVs (mean CN, 0.46-0.65). Atlas exposure for Group A led to significantly increased interobserver agreement for CTVA (mean initial CN, 0.68, after atlas use, 0.76; p = .03) and increased agreement with the expert reference (initial mean CN, 0.58; after atlas use, 0.69; p = .02). For the GTV and CTVB, neither the interobserver nor the expert agreement was altered after atlas exposure. CONCLUSION: Consensus guideline atlas implementation resulted in a detectable difference in interobserver agreement and a greater approximation of expert volumes for the CTVA but not for the GTV or CTVB in the specified case. Visual atlas inclusion should be considered as a feature in future clinical trials incorporating conformal RT.

Parametric survival models for predicting the benefit of adjuvant chemoradiotherapy in gallbladder cancer.

The Cox proportional hazards model is the most commonly used survival model in oncology; however, this semi-parametric model may not be the most appropriate survival model when the proportionality assumption does not hold. In this study, we consider the use of several types of accelerated failure time parametric survival techniques for modeling the benefit of adjuvant chemoradiotherapy for gallbladder cancer. In comparing the Weibull, exponential, log-logistic, and log-normal models, we found that the log-normal had the most favorable Akaike Information Criterion, and additional analyses of this model indicated that our gallbladder cancer dataset exhibited a good fit with the log-normal cumulative hazard function. This log-normal survival model can be used to help predict which patients will benefit from adjuvant chemoradiotherapy.

Conditional survival and the choice of conditioning set for patients with colon cancer: an analysis of NSABP trials C-03 through C-07.

PURPOSE: Colon cancer overall survival (OS) is usually computed from the time of diagnosis. Survival gives the initial prognosis but does not reflect how prognosis changes with changing hazard rates over time. Conditional survival (probability of surviving y additional years given they have survived x years [CS or OS|OS]) is an alternative measure that accounts for elapsed time since diagnosis, providing more relevant prognostic information. We extend the concept of CS to condition on the set of patients alive, recurrence-free, and second primary cancer-free (disease-free survival [OS|DFS]). PATIENTS AND METHODS: Using data from National Surgical Adjuvant Breast and Bowel Project trials C-03 through C-07, 5-year OS|DFS was calculated on patients who were disease free up to 5 years after diagnosis, stratified by age, stage, nodal status, and performance status (PS). RESULTS: For stage II, OS|DFS improved from 87% to 92% at 5 years. For stage III, OS|DFS improved from 69% to 88%. Patients younger than 50 years showed OS|DFS improvement from 79% to 95%; those older than 70 years showed no sustained increase in OS|DFS. Node-negative patients with > or = 12 nodes resected showed little change (89% to 94%); those with more than four positive nodes showed an improvement (57% to 86%). Patients with a PS of 0 or 1 demonstrated a small improvement; those with a PS of 2 did not (64% to 58%). CONCLUSION: Prognosis improves over time for almost all groups of patients with colon cancer, especially those with positive nodes. OS|DFS is a more relevant measure of prognosis for those who have already survived disease free a period of time after diagnosis.

Image-guided intensity-modulated radiotherapy (IG-IMRT) for biliary adenocarcinomas: Initial clinical results.

PURPOSE: Biliary tract lesions are comparatively rare neoplasms, with ambiguous indications for radiotherapy. The specific aim of this study was to report the clinical results of a single-institution biliary tract series treated with modern radiotherapeutic techniques, and detail results using both conventional and image-guided intensity-modulated radiation therapy (IG-IMRT). METHODS AND MATERIALS: From 2001 to 2005, 24 patients with primary adenocarcinoma of the biliary tract (gallbladder and extrahepatic bile ducts) were treated by IG-IMRT. To compare outcomes, data from a sequential series of 24 patients treated between 1995 and 2005 with conventional radiotherapy (CRT) techniques were collected as a comparator set. Demographic and treatment parameters were collected. Endpoints analyzed included treatment-related acute toxicity and survival. RESULTS: Median estimated survival for all patients completing treatment was 13.9 months. A statistically significant higher mean dose was given to patients receiving IG-IMRT compared to CRT, 59 vs. 48Gy. IG-IMRT and CRT cohorts had a median survival of 17.6 and 9.0 months, respectively. Surgical resection was associated with improved survival. Two patients (4%) experienced an RTOG acute toxicity score>2. The most commonly reported GI toxicities (RTOG Grade 2) were nausea or diarrhea requiring oral medication, experienced by 46% of patients. CONCLUSION: This series presents the first clinical outcomes of biliary tract cancers treated with IG-IMRT. In comparison to a cohort of patients treated by conventional radiation techniques, IG-IMRT was feasible for biliary tract tumors, warranting further investigation in prospective clinical trials.